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HJ45  .Sm52  A  practical  treatise 


Columbia  ©nibersiitp 
in  tf)e  Citp  of  ^ciu  gorfe 

College  o!  ^tP^icians  anb  burgeons 


(giben  6p 

Br.  Obtain  p.  Cragin 

1859-1918 


^ 


klUrla 


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PRACTICAL  T^4TISE 


DISEisfSE^I^  CHILDEEN 


EUSTACE     SMITH,     M.D., 

FELLOW  OF  THE  EOYAL  COLLEGE  OF  PHYSICIANS  ;   PHYSICIAN  TO  HIS  MAJESTY  THE  KING  OF  THE 

BELGIANS  ;   PHYSICIAN  TO  THE  EAST  LONDON  CHILDEENS'  HOSPITAL,  AND  TO  THE 

VICTORIA  PAEK  HOSPITAL  FOK  DISEASES  OF  THE  CHEST 


THIED  EDITION. 


NEW  YORK 

WILLIAM    WOOD     &    COMPANY 

56  &  58  Lafayette  Place 

1886 


COPTRIGHT,    1884, 

By  WILLIAM   "WOOD  &  COMPANy 


INSCRIBED      TO 


Sir  ^nirretD   (EUrk,   Bart.,   M.'B., 


IN  TOKEN  OF   SINCERE   FRIENDSHIP 


BY  THE   AUTHOR. 


PREFACE. 


It  was  r.ot  without  hesitation  that  the  author  consented  to  the  pro- 
posal made  to  him  by  Messrs.  Wood  &  Company,  of  New  York,  that 
he  should  write  for  them  a  complete  Treatise  on  the  Diseases  of  In- 
fancy and  Childhood.  The  length  of  time  which  would  be  required 
for  the  completion  of  a  task  so  considerable,  and,  especially,  the  knowl- 
edge that  many  manuals  of  varying  merit  were  already  in  the  field,  in- 
disposed him  to  attempt  a  work  which  must  necessarily  prove  not  only 
long  but  laborious.  Encouraged,  however,  by  the  reflection  that  his  op- 
portunities for  studying  these  complaints  had  been  abundant ;  that  in  the 
course  of  more  than  twenty  years  he  had  acquired  a  mass  of  valuable 
material,  and  that  of  existing  books  few  dealt  with  more  than  a  part 
of  the  subject,  he  thought  himself  justified  in  believing  that  a  treatise 
which  undertook  to  discuss  the  whole  subject  of  disease  in  early  life, 
and  to  deal  with  the  matter  purely  from  a  clinical  stand-point,  might 
not  be  without  its  uses. 

The  constitutional  peculiarities  of  childhood,  and  the  weakness  due 
to  immaturity,  so  shape  the  course  and  symptoms  of  disease  that  there 
are  few  complaints  which  do  not  assume  special  features  when  present 
in  the  young.  Consequently  the  author  has  not  hesitated  to  admit 
into  his  pages  descriptions  of  every  form  of  illness  which  is  capable  of 
being  influenced  in  its  manifestations  by  the  early  age  of  the  patient. 
Those  only  have  been  purposely  omitted  which,  like  diabetes,  present 
exactly  the  same  characters  in  the  child  that  they  do  in  the  adult. 

Each  subject  has  been  treated  as  fully  as  the  space  would  allow, 
but  many  faults  of  omission  may,  no  doubt,  be  discovered.  The 
author,  however,  has  striven  to  satisfy  all  clinical  requirements,  and 
where  much  must  be  left  out,  that  the  book  may  be  kept  within  rea- 
sonable limits,  has  been  anxious  to  omit  nothing  of  real  value  to  the 
practitioner. 

In  the  composition  of  the  work  the  use  of  statistics  has  been  gener- 
ally avoided,  for  unless  dealing  with  enormous  numbers  little  that  is 


VI  PEEFACE. 

trustworthy  can  be  obtained  from  this  method  of  inquiry.  In  fact, 
there  can  be  little  doubt  that  very  erroneous  impressions  have  been 
sometimes  derived  from  statistical  calculation  based  upon  an  insufficient 
number  of  cases. 

In  order  to  increase  the  usefulness  of  the  book,  much  care  has  been 
bestowed  upon  the  sections  relating  to  diagnosis  and  treatment.  Ko 
attempt,  however,  has  been  made  to  include  in  the  directions  for  treat- 
ment an  enumeration  of  all  the  remedies  which  have  been  suggested 
for  the  cure  of  the  several  forms  of  illness.  Such  excess  of  detail  not 
only  fills  the  page  with  information  often  of  doubtful  value,  but  tends 
rather  to  confuse  the  reader  than  to  instruct  him.  Moreover,  it  gives 
to  this  branch  of  therapeutics  an  importance  which,  in  the  case  of  chil- 
dren, it  does  not  always  possess.  In  the  case  of  a  yoimg  patient,  judg- 
ment in  feeding  and  care  in  sanitary  arrangements  not  seldom  consti- 
tute the  sole  necessary  treatment  of  the  illness.  Quiet,  rest,  appropriate 
food,  and  plenty  of  fresh  air  will  often  restore  the  health  without  the 
aid  of  physic  ;  or  if  physic  seem  called  for,  the  remedies  needed  are 
simple  and  few.  But  whatever  be  the  nature  of  the  malady,  and  how- 
ever elaborate  may  be  the  medication  required,  the  details  of  nursing 
should  always  take  precedence  of  those  of  drug-giving.  Keeping  this 
truth  in  view,  the  author  has  been  careful  to  give  due  prominence  to 
the  subjects  of  diet  and  hygiene ;  and  in  the  matter  of  drugs  has  con- 
fined himself,  for  the  most  part,  to  recommending  those  only  which 
experience  has  taught  him  to  value,  and  upon  which,  therefore,  he  has 
himself  been  accustomed  to  rely. 

For  purposes  of  illustration  a  number  of  concisely  narrated  cases 
have  been  introduced  into  the  text.  Most  of  these  have  been  selected 
from  the  author's  case-books,  but  a  few  are  taken  from  the  practice  of 
his  hospital  colleagues.  To  these  colleagues,  for  their  kindness  in 
placing  their  cases  at  his  disposal,  the  author  desires  to  express  his 
deep  obligations. 

George  Street,  Hanover  Square, 
June,  1884. 


TABLE   OF   CONTENTS. 


Introductory  Chapter 1 

Physiological  peculiarities  of  early  life,  1  ;  causes  of  sudden  death,  5  ;  conva- 
lescence, 5  ;  definition  of  infancy  and  early  childhood,  5  ;  clinical  examin- 
ation of  infants,  6  ;  inspection  of  the  face,  6  ;  attitude,  8  ;  cry,  8  ;  ab- 
sence of  cry,  9  ;  the  pulse,  9  ;  the  respirations,  10  ;  the  temperature,  10  ; 
pyrexia  from  rapid  growth,  11 ;  movements  of  the  chest  and  belly  in 
breathing,  12  ;  inspection  of  the  mouth  and  throat,  13  ;  treatment,  14 ; 
forced  feeding,  14  ;  reducing  temperature,  15  ;  baths,  16  ;  internal  rem- 
edies, 18  ;  abuse  of  aperients,  19. 


|)avt  1. 
THE   ACUTE  INFECTIOUS  DISEASES. 

CHAPTER  I. 

Measles 21 

The  contagious  principle,  21 ;  morbid  anatomy,  22  ;  symptoms,  22  ;  pre-emp- 
tive period,  22 ;  the  rash,  23  ;  catarrh,  23 ;  asthenic  measles,  24 ;  re- 
lapses, 24  ;  complications,  25  ;  sequelae,  26  ;  diagnosis,  26  ;  prognosis,  27  ; 
treatment,  28. 

CHAPTER,  II. 
Epidemic  Roseola.  .     30 

Symptoms,  30  ;  diagnosis,  31 ;  treatment,  31. 

CHAPTER  III. 

Scarlet  Fever , 32 

Causation,  32  ;  morbid  anatomy,  33  ;  symptoms,  33  ;  invasion,  34 ;  eruptive 
stage,  34 ;  the  rash,  34 ;  temperature,  35 ;  the  desqua,mative  stage,  36 ; 
malignant  scarlet  fever,  36  ;  complications  and  sequelae,  37  ;  scarlatinous 
rheumatism,  38  ;  albuminuria  and  ursemic  symptoms,  39 ;  latent  scarlet 
fever,  40  ;  diagnosis,  41 ;  prognosis,  42  ;  illustrative  case,  42  ;  treatment, 
43. 

CHAPTER  IV. 
Chicken-pox 48 

Symptoms,  48  ;  temperature,  48  ;  gangrenous  varicella,  49  ;  treatment,  50. 


Vlll  CONTENTS. 

CHAPTER  V. 

rAGB 

Cow-pox — Vaccination 51 

Symptomp  and  course,  51  ;  protective  value  of  vaccination,  52  ;  metliod  of 
vaccinating,  53  ;  occasional  sequelae,  54. 

CHAPTER  VI. 

Sjiall-pox 55 

Morbid  anatomy,  55  ;  symptoms,  56  ;  incubation,  56 ;  invasion,  56  ;  compli- 
cations, 59  ;  varieties,  60 ;  diagnosis,  61  ;  prognosis,  63 ;  treatment,  62. 

CHAPTER  Vn. 

Mumps %. , 65 

Morbid  anatomy,  65  ;  symptoms,  65  ;  incubation,  65  ;  temperature,  65 ;  me- 
tastasis, 66  ;  deafness,  66  ;  diagnosis,  67  ;  treatment,  67. 

CHAPTER  Vin. 

Cerebro-spinal  Fever 68 

Causation,  68  ;  morbid  anatomy,  68  ;  symptoms,  69  ;  rasb,  69  ;  nervous  symp- 
toms, 69  ;  temperature,  70  ;  paralysis,  70 ;  convulsions,  70 ;  varieties, 
71 ;  form  in  infancy,  71 ;  diagnosis,  72 ;  prognosis,  73  ;  treatment,  73. 

CHAPTER  IX. 

Enteric  Fever 74 

Causation,  74 ;  morbid  anatomy,  75  ;  symptoms,  76 ;  first  week,  76  ;  second 
week,  77 ;  third  week,  77  ;  digestive  organs,  78  ;  the  urine,  78  ;  special 
senses,  79  ;  temperature,  79  ;  duration,  80  ;  case,  80  ;  mode  of  death,  81 ; 
relapses,  82  ;  secondary  pyrexia,  82 ;  convalescence,  82  ;  diagnosis,  88 ; 

prognosis,  84  ;  treatment,  85. 

CHAPTER  X. 

Diphtheria 88 

Diphtheria  and  croup,  88  ;  causation,  90  ;  morbid  anatomy,  91 ;  symptoms, 
93;  mild  form,  93  ;  severe  form,  94;  albuminuria,  95;  laryngeal  diph- 
theria, 95  ;  dj'spnoea,  96  ;  malignant  form.  97  ;  case,  97  ;  secondary  diph- 
theria, 97  ;  complications,  97;  nasal  diphtheria,  98  ;  cutaneous  diphtheria, 
98  ;  inflammatory  complications,  98  ;  thrombosis  of  heart,  98 ;  cardiac 
dyspnoea,  98  ;  apnoea  from  laryngeal  obstruction,  99  ;  sudden  death,  99  ; 
paralysis,  99  ;  diagnosis,  100  ;  prognosis,  102 ;  treatment,  general,  103 ; 
local,  104  ;  tracheotomy,  105. 

CHAPTER  XI. 

Erysipelas 109 

Causation,  109  ;  morbid  anatomy,  110  ;  symptoms.  111 ;  rash,  111  ;  fever, 
111 ;  complications,  111  ;  diagnosis,  112  ;  prognosis,  112  ;  treatment,  113. 

CHAPTER  Xn. 

Whooping-cough 114 

Causation,  114  ;  duration  of  infection,  114 ;  pathology,  114  ;  nature  of  the 
disease,  115  ;  symptoms,  115  ;  the  cough,  116  ;  the  whoop,  116  ;  haemor- 
rhages, 116;  complications,  117;  ulceration  of  tongue,  117;  bleeding 
from  ears,  etc.,  118;  digestive  troubles,  118;  nervous  accidents,  118; 
pulmonary  lesions,  119  ;  sequelae,  120;  diagnosis,  122;  prognosis,  123; 
treatment,  124 ;  of  complications,  127. 


CONTENTS.  iX 

|3art  2. 
GEKEKAL  DISEASES  KOT  mFECTIOUS. 

CHAPTER  I.  PAGE 

Rickets , 139 

Causation,  129  ;  bad  feeding,  129  ;  bad  air,  130  ;  relation  to  syphilis,  131  ;  re- 
lation to  tuberculosis.  131  ;  nature,  131  ;  morbid  anatomy,  132  ;  ossifica- 
tion of  bone,  132  ;  softening  of  bones,  133  ;  changes  in  internal  organs, 
133  ;  the  urine,  134;  effects  of  bone  changes,  134  ;  on  the  contents  of  the 
chest  cavity,  134;  relation  to  osteo-malacia,  135;  "congenital  rickets," 
135  ;  symptoms,  136  ;  distortion  of  bones,  137  ;  chest,  139  ;  spine,  139  ; 
long  bones,  140  ;  general  nutrition,  140 ;  complications,  142  ;  diagnosis, 
143  ;  prognosis,  143  ;  treatment,  144. 

CHAPTER  11. 
Ague 147 

Causation,  147 ;  morbid  anatomy,  147  ;  symptoms,  148  ;  the  cold  stage,  148 ; 
the  hot  stage,  148  ;  the  sweating  stage,  148  ;  stages  often  ill  developed, 
148  ;  temperature,  149  ;  urine,  149  ;  malignant  form,  149  ;  ansemia,  149  ; 
hsematuria,  149  ;  diagnosis,  149  ;  prognosis,  150  ;  treatment,  151  ;  hypo- 
dermic injection  of  quinine,  151. 

CHAPTER  m. 

Acute  Rheumatism 153 

Frequency  in  children,  153  ;  causation,  153 ;  morbid  anatomy,  154 ;  symp- 
toms, 154  ;  inflammation  of  joints,  155  ;  pericarditis,  155  ;  fewness  of  its 
symptoms,  155  ;  illustrative  case,  155  ;  occasional  severity  of  symptoms 
155  ;  pericardial  friction,  156  ;  effusion,  156  ;  elevation  of  heart's  apex, 

157  ;  illustrative  case,  157  ;   suppurative  pericarditis,  157  ;  endocarclitis 

158  ;  ulcerative  endocarditis,  158  ;  pleurisy,  158  ;  illustrative  case,  158 
pneumonia,  159  ;  hyper-pyrexia,    159  ;  rheumatism  of  abdominal  wall 

159  ;  fibroid  nodules,  16U  ;  duration,  160  ;  relapses,  160  ;  chronic  rheu 
matic  pains,  161  ;  diagnosis,  161  ;  of  pericarditis,  161  ;  endocarditis,  162 
ulcerative  endocarditis,  162  ;  prognosis,  162  ;  occasional  disappearance  of 
cardiac  munnurs,  163  ;  treatment,  163  ;  salicylate  of  soda,  164  ;  impor- 
tance of  rest,  165. 

CHAPTER  IV. 

Spontaneous  Gangbene 166 

Pathology,  166  ;  morbid  anatomy,  167  ;  symptoms,  167  ;  disseminated  form, 
168  ;  illustrative  cases,  168  ;  gangrene  of  extremities,  169  ;  dry  and  moist 
varieties,  169  ;  of  vulva,  170  ;  diagnosis,  170  ;  prognosis,  171  :  treatment, 
171. 


J)  art  3. 
THE  DIATHETIC  DISEASES. 

CHAPTER  I. 
Scrofula 173 

Causation,  173  ;  hereditary  tendency,  173  ;  exciting  causes,  174  ;  morbid  an- 
atomy, 174  ;  caseation  of  glands,  175  ;  symptoms,  175  ;  variety  of  the 
lesions,  176  ;  cutaneous  abscesses,  177  ;  disease  of  bones  and  joints,  178  ; 
of  the  spine,  178  ;  caseation  of  glands,  179  ;  of  cervical  glands,  179  ;  of 
bronchial  glands,  180 ;  its  consequences,  181  ;  asthmatic  attacks,  182 ; 
^alteration  in  physical  signs,  182  ;  of  mesenteric  glands,  183 ;  its  conse- 
quences, 184  ;  diagnosis,  185  ;  prognosis,  186 ;  treatment,  187. 


X  CONTENTS. 

CHAPTER  II.  PAGB 

Acute  Tuberculosis 190 

Three  forms,  190  ;  causation,  190  ;  hereditary  tendency,  190  ;  acute  specific 
diseases,  191  ;  the  tubercle  bacillus,  191  ;  morbid  anatomy,  191  ;  the  gray 
granulation,  192 ;  the  giant  cell,  192 ;  lung  changes,  198  ;  lesions  of  in- 
testines, 198  ;  of  the  spleen,  193  ;  of  the  Madder,  193 ;  nature  of  cheesy 
matter,  194  ;  symptoms,  194 ;  gradual  onset,  194  ;  temperature,  195  ; 
oedema  of  legs,  195  ;  local  symptoms,  195  ;  in  brain,  195  ;  in  lung,  196  ; 
illustrative  case,  196  ;  in  bladder,  197 ;  in  other  organs,  197  ;  duration, 

198  ;  diagnosis,  198  ;  from  gastric  catarrh,  198 ;  from  infantile  atrophy, 

199  ;  of  pulmonary  complication,  199  ;  of  tubercle  of  bladder,  199  ;  prog- 
nosis, 200  ;  treatment,  200. 

CHAPTER  III. 

Infantile  Syphilis 202 

Causation,  202 ;  influence  of  the  father  and  mother,  202 ;  Colles's  law,  202  ; 
acquired  syphilis,  203  ;  morbid  anatomy,  208  ;  affection  of  miicous  mem- 
branes, 204  ;  of  solid  organs,  204 ;  of  bones,  206  ;  two  varieties,  206  ; 
Parrot's  views,  206  ;  dactylitis,  207  ;  affection  of  bones  of  skull,  207  ; 
cranio-tabes,  208  ;  symptoms,  208  ;  snuffling,  209  ;  rash,  209  ;  complexion, 
209  ;  affection  of  hair  and  nails,  210  ;  the  cry,  210  ;  thickening  of  the 
bones,  210  ;  pseudo-paralysis,  210  ;  true  paralysis,  210 ;  general  nutrition, 
210 ;  relapses,  211  ;  sequelae,  211 ;  diagnosis,  211  ;  prognosis,  213  ;  treat- 
ment, 218. 


|3art  4. 
DISEASES  OF   THE   DUCTLESS  GLAIsTDS  AND   BLOOD. 

CHAPTER  I. 

Leucocythemia 216 

Causation,  216  ;  morbid  anatomy,  216 ;  symptoms,  217 ;  enlargement  of 
spleen,  217;  anasmia,  217;  temperature,  218;  hemorrhages,  218;  en- 
largement of  glands,  218  ;  diagnosis,  218  ;  from  enteric  fever,  218 ;  from 
lymphadenoma,  219  ;  prognosis,  219  ;  treatment,  219. 

CHAPTER  II. 

Lymphadenoma 220 

Causation,  220 ;  morbid  anatomy,  220  ;  changes  in  lymphatic  glands,  221  ;  in 
spleen,  221  ;  in  liver,  222  ;  kidneys,  222  ;  adenoid  new  growths,  222  ; 
blood,  222  ;  symptoms,  222  ;  regular,  228  ;  illustrative  case,  223  ;  glandu- 
lar swellings,  224 ;  temperature,  224  ;  cachectic  stage,  224 ;  ansemia,- 
224  ;  early  local  symptoms,  225  ;  illustrative  case,  225  ;  accidental  symp- 
toms, 226  ;  pressure  signs,  226  ;  paralysis,  226  ;  illustrative  case,  226 ; 
diagnosis,  227 ;  prognosis,  227  ;  treatment,  227. 

CHAPTER  III. 

Anemia 229 

Frequency  of  impoverishment  of  the  blood  in  children,  229  ;  reasons  for  this, 
229 ;  use  of  the  blood  in  niitrition,  230 ;  causation,  230  ;  two  classes,  230  ; 
morbid  anatomy,  231  ;  idiopathic  anaemia,  232  ;  symptoms,  232  ;  com- 
plexion, 232  ;  breathlessness,  232 ;  anaemic  murmurs,  233  ;  epistaxis,  233  ; 
headache,  233  ;  symptoms  of  idiopathic  anaemia,  238 ;  diagnosis,  233 ; 
prognosis,  234  ;  treatment,  284  ;  diet,  234 ;  attention  to  general  hygiene, 
234  ;  iron,  235  ;  arsenic,  235  ;  cold-water  packing  and  massage,  236. 


CONTENTS.  XI 


CHAPTER  IV. 

PAGE 

Enlargement  op  the  Spleen  . . . , 237 

Causation  of  splenic  enlargement,  237  ;  simple  hyperplasia,  238  ;  morbid  anat- 
omy, 238  ;  symptoms,  238 ;  anjemia,  238  ;  oedema,  238  ;  the  Mood,  239  ; 
cases,  239  ;  gastro-intestinal  troubles,  239  ;  diagnosis,  240 ;  prognosis, 
240 ;  treatment,  240  ;  abuse  of  mercurial  frictions,  241. 

CHAPTER  V. 

HEMOPHILIA .    242 

Causation,  242 ;  morbid  anatomy,  242  ;  symptoms,  243  ;  three  grades,  243  ; 
haemorrhages,  243;  joint  affection,  244;  diagnosis,  245;  prognosis,  245; 
treatment,  245. 

CHAPTER  VI. 

Purpura 247 

Two  varieties,  247  ;  causation,  247  ;  morbid  anatomy,  247 ;  pathology,  248 ; 
symptoms,  248  ;  eruption,  248  ;  illustrative  case,  249  ;  pains  in  limbs, 
249  ;  hsemorrhagic  purpura,  249  ;  various  haemorrhages,  249  ;  purpura 
rheumatica,  249  ;  anaemia,  250  ;  temperature,  250;  illustrative  case,  250; 
oedema,  250 ;  cerebral  haemorrhage,  251  ;  convulsions,  251  ;  course,  251 ; 
diagnosis,  251 ;  prognosis,  251 ;  treatment,  251. 

CHAPTER  VII. 

Scurvy 253 

Causation,  253  ;  morbid  anatomy,  254  ;  periosteal  extravasation,  254  ;  pathol- 
ogy, 255  ;  symptoms,  255 ;  tenderness,  256  ;  swelling,  256  ;  petechias,  256  ; 
separation  of  epiphyses,  256  ;  the  gums,  256  ;  cachexia,  256  ;  temperature, 
257  ;  course,  257  ;  diagnosis,  257 ;  prognosis,  258 ;  treatment,  258. 


|3art  5. 
DISEASES   OF  THE  ^ERYOUS   SYSTEM. 

CHAPTER  I. 

General  Considerations 260 

Excitability  of  the  nervous  system  in  early  life,  260  ;  value  of  various  symp- 
toms, 261  ;  squint,  261  ;  nystagmus,  261  ;  state  of  the  pupils,  261 ;  de- 
lirium, 262 ;  drowsiness,  262 ;  loss  of  consciousness,  262 ;  changes  of 
temper,  262  ;  tremours,  263  ;  spasms,  263  ;  paralysis,  263  ;  aphasia,  263 ; 
rigidity,  264  ;  retraction  of  head,  264  ;  vomiting,  264 ;  the  breathing, 
264 ;  the  pulse,  265 ;  cerebral  flush,  265 ;  the  urine,  265 ;  hysterical 
symptoms,  265. 

CHAPTER  II. 
Laryngismus  Stridulus 267 

Causation,  267  ;  association  with  rickets,  267  ;  pathology,  268  ;  exciting  causes, 

268  ;  illustrative  case,  268 ;  symptoms,  269  ;  description  of  the  seizure, 

269  ;  duration  of  attacks,  269  ;  illustrative  case,  269  ;  spasm  limited  to 
glottis,  270 ;  characters  of  the  spasm  in  new-born  infants,  270  ;  mode  of 
death,  270  ;  incarceration  of  epiglottis,  271  ;  diagnosis,  271  ;  prognosis, 

.  272 ;  treatment,  272  ;  ammonia,  272  ;  cold  bathing,  272  ;  fresh  air,  272  ; 
antispasmodics,  273  ;  tonics,  273. 


XU  CONTENTS. 


CHAPTER  in. 

FA6B 

Tonic  Contraction  of  the  Extremities 274 

Usually  associated  with  laryngismus  stridulus  and  reflex  convulsions,  274  ;  not 
uncommon  in  the  subjects  of  rickets,  274 ;  symptoms,  274  ;  pain,  274  ; 
contraction  of  muscle,  274  ;  usual  seat,  274 ;  influence  of  manipulation, 
275  ;  is  usually  bilateral,  275  ;  if  severe,  persists  during  sleep,  275 ;  sen- 
sation unaffected,  275  ;  diagnosis,  275  ;  prognosis,  276 ;  treatment,  276. 

CHAPTER  IV. 

Convulsions ,. 277 

Common  during  the  first  two  years  of  life,  277 ;  causation,  278  ;  symptoms, 
279  ;  description  of  a  paroxysm,  279  ;  drowsiness,  280  ;  temporary  paral- 
ysis, 280  ;  congestion  of  brain,  280  ;  illustrative  case,  280 ;  diagnosis,  281  ; 
from  cerebral  convulsions,  281  ;  from  epilepsy,  282  ;  prognosis,  283  ;  in- 
fluence on  brain  development,  283  ;  treatment,  284  ;  warm  bath,  284 ; 
chloral,  284 ;  nitrite  of  amyl,  285  ;  stimulants,  285  ;  tonics,  285. 

CHAPTER  V. 

Epilepst 286 

Causation,  286  ;  hereditary  tendency,  286  ;  injuries,  286  ;  a  fit  of  convulsions, 
286  ;  illustrative  case,  286 ;  pathology,  287  ;  symptoms,  288  ;  epilepsia 
gravior,  288  ;  epilepsia  mitior,  288  ;  a  fit  of  epileptic  vertigo,  288 ;  illus- 
trative case,  289 ;  frequency  of  attacks,  289  ;  association  with  chorea, 
290  ;  diagnosis,  290  ;  from  syncope,  290  ;  from  hysterical  fits,  290  ;  prog- 
nosis, 291 ;  treatment,  291 ;  general  attention  to  health,  291  ;  diet,  292 ; 
the  bromides,  292  ;  strychnia,  292  ;  nitrite  of  amyl,  293. 

CHAPTER  VI. 

Megrim 294 

Causation,  294  ;  pathology,  294 ;  symptoms,  295  ;  headache,  295 ;  impairment 
of  sight,  295  ;  of  other  senses,  295  ;  illustrative  case,  296  ;  pains  in  limbs, 
296  ;  illustrative  case,  296 ;  diagnosis,  296  ;  treatment,  297 ;  strychnia 
and  ergot,  297. 

CHAPTER  Vn. 
Chorea 299 

Causation,  299  ;  association  with  rheumatism,  299  ;  pathology,  300 ;  various 
theories,  300  ;  symptoms,  301  ;  disordered  movements,  301 ;  inco-ordina- 
tion  of  voluntary  movement,  302  ;  sleeplessness,  302  ;  sensory  disturb- 
ances, 302  ;  hemichorea,  302  ;  the  urine,  803 ;  mental  state,  303 ;  tem-- 
perature,  303  ;  weakness  of  muscle,  303  ;  heart  murmurs,  304 ;  course 
and  duration,  304  ;  diagnosis,  304  ;  prognosis,  304  ;  treatment,  305  ;  hy- 
giene, 305  ;  moral  treatment,  305  ;   drugs,  305  ;  massage,  306. 

CHAPTER  VIII. 

Idiopathic  Tetanus 308 

In  infants,  rare  in  England,  308  ;  causation,  308  ;  influence  of  general  unsan- 
itary conditions,  309  ;  morbid  anatomy,  309  ;  symptoms,  310 ;  dijficulty 
of  swallowing,  310  ;  stiffness  of  jaws,  310 ;  temperature,  310  ;  attacks  of 
spasm,  310;  tonic  rigidity,  310;  illustrative  case,  310;  duration,  311; 
tetanus  in  older  children,  311 ;  illustrative  case,  311  ;  diagnosis,  312  ; 
from  strychnia  poisoning,  312  ;  prognosis,  312  ;  treatment,  313  ;  forced 
feeding,  313 ;  Calabar  bean,  313  ;  chloral,  313  ;  illustrative  case,  314. 


CONTENTS.  Xiii 

CHAPTER  IX. 

PAGR 

Congestion  of  the  Bkain 316 

Circulation  of  blood  in  the  brain,  316  ;  causation,  316  ;  two  forms,  316  ;  rela- 
tion to  dentition,  316  ;  and  convulsions,  317  ;  minute  embolisms,  317 ; 
morbid  anatomy,  317 ;  symptoms,  318  ;  irritative  stage  not  clinically 
recognisable,  318  ;  the  common  form,  318  ;  illustrative  case,  318  ;  throm- 
bosis of  cerebral  sinuses,  319  ;  diagnosis,  319  ;  prognosis,  320  ;  treatment, 
331. 

CHAPTER  X. 

Cekebraii  Hemorrhage 333 

Only  common  in  still-born  children,  333  ;  causation,  333  ;  sometimes  the  re- 
sult of  aneurism  of  a  cerebral  artery,  383  ;  morbid  anatomy,  333  ;  men- 
ingeal haemorrhage,  333 ;  cerebral  haemorrhage,  333 ;  cause  of  aneurism, 
333 ;  symptoms,  334 ;  of  meningeal  haemorrhage,  334 ;  low  tempera- 
ture, 334  ;  stupor  and  convulsions,  334  ;  resemblance  to  simple  menin- 
gitis, 335 ;  illustrative  case,  335 ;  cerebral  haemorrhage,  336  ;  illusti'ative 
case,  326  ;  haemorrhage  from  rupture  of  aneurism,  337  ;  illustrative  case, 
327  ;  diagnosis,  338  ;  prognosis,  339  ;  treatment,  329. 

CHAPTER  XI. 

Cerebral  Tumour 330 

Cerebral  growth  usually  tubercular,  330  ;  morbid  anatomy,  330  ;  varieties  of 
growths,  331 ;  symptoms,  331 ;  headache,  333 ;  convulsions,  333  ;  loss  of 
special  sense,  333  ;  ophthalmoscopic  appearances,  333 ;  illustrative  case, 
333  ;  gliomatous  tumour,  333  ;  tubercular  growth,  335 ;  illustrative  case, 
335  ;  two  stages  often  seen,  336 ;  illustrative  case,  336  ;  cerebellar  tumour, 
337  ;  characteristic  symptoms,  337  ;  other  seats,  337 ;  diagnosis,  337 ;  prog- 
nosis, 339  ;  treatment,  339. 

CHAPTER  XII. 

Chronic  Hydrocephalus ' 340 

Causation,  340  ;  morbid  anatomy,  341  ;  effect  of  pressure  on  the  brain  and 
skull,  341  ;  symptoms,  343  ;  distention  of  skull,  342 ;  imperfect  nutri- 
tion, 343  ;  intelligence,  343  ;  nervous  symptoms,  343  ;  illustrative  case, 
343  ;  the  acquired  form,  344  ;  spontaneous  evacuation  of  fluid,  344 ;  diag- 
nosis, 345  ;   prognosis,  345  ;  treatment,  345. 

CHAPTER  XIII. 

Otitis  and  its  Consequences 346 

Extension  of  inflammation  from  the  tympanum  to  the  skull  cavity,  346 ;  cau- 
sation, 346  ;  morbid  anatomy,  347  ;  symptoms,  348  ;  extension  of  inflam- 
mation to  the  meninges,  348  ;  purulent  meningitis,  349  ;  temperature, 
349 ;  convulsions,  349  ;  illustrative  case,  349  ;  phrenitic  form,  350  ;  de- 
lirium, 350  ;  temperature,  350  ;  thrombosis  of  the  cerebral  sinuses,  351  ; 
encephalitis,  351  ;  convulsions,  351  ;  stupor,  351 ;  paralysis,  351 ;  illus- 
trative case,  352 ;  diagnosis,  353  ;  prognosis,  354  ;  treatment,  354. 

CHAPTER  XIV. 

Tubercular  Meningitis 355 

Common  at  all  ages  of  childhood,  355  ;  causation,  355  ;  morbid  anatomy,  356 ; 
symptoms,  357  ;  premonitory,  357  ;  two  forms,  357  ;  primary  meningitis, 
357  ;  three  stages,  358  ;  first  stage,  358  ;  second  stage,  359  ;  third  stage, 
360  ;  duration  of  illness,  361  ;  secondary  meningitis,  361  ;  common  in 
infants,  363 ;  anomalous  cases,  363 ;  diagnosis,  363 ;  illustrative  case, 
363  ;  prognosis,  365  ;  treatment,  365. 


XIV  CONTENTS. 


CHAPTER  XV. 

FAOB 
PAKAIiYSIS   OF  THE    PORTIO   DURA 367 

Course  of  tlie  facial  nerve  in  the  Fallopian  canal,  367  ;  causation  of  the  par- 
alysis, 867  ;  symptoms,  368  ;  illustrative  case,  368  ;  diagnosis  and  prog- 
nosis, 369  ;  treatment,  370. 

CHAPTER  XVI. 

Acute  Infantile  Spinaij  Paralysis 371 

Causation,  371  ;  morbid  anatomy,  372  ;  symptoms,  373  ;  onset,  373  ;  com- 
pleteness of  the  paralysis,  374  ;  rapid  limitation  of  the  paralyzed  area, 
374  ;  wasting  of  muscles,  375  ;  stage  of  contraction,  375  ;  mechanism  of 
the  deformities,  375  ;  diagnosis,  377  ;  prognosis,  377  ;  treatment,  378. 

CHAPTER  XVn. 

Spasmodic  Spinal  Paralysis 380 

Morbid  anatomy,  380  ;  sj'mptoms,  380  ;  rigidity  of  joints,  381  ;  diagnosis, 
382  ;  prognosis,  382  ;  treatment,  382. 

CHAPTER  XVin. 

PSEUDO-HYPERTROPHIC   PARALYSIS 384 

Causation,  384  ;  morbid  anatomy,  384  ;  symptoms,  385  ;  enlargement  of  mus- 
cles, 385  ;  progressive  weakness,  385  ;  occasional  atrophy  of  muscle,  386  ; 
contractions,  386  ;  course,  387  ;  diagnosis,  387  ;  prognosis,  388  ;  treat- 
ment, 388. 

CHAPTER  XIX. 
Idiocy 389 

Causation,  389  ;  morbid  anatomy,  390  ;  classification,  391  ;  symptoms,  391 ; 
cretinism,  392  ;  illustrative  cases,  393  ;  degrees  of  mental  development, 

394  ;  diagnosis,  395  ;  development  of  the  senses  in  the  healthy  infant, 

395  ;  prognosis,  396  ;  treatment,  397. 


Jpart  6. 
DISEASES   OF  THE   OKGANS   OF  RESPIRATIOK. 

CHAPTER  I. 
Examination  op  the  Chest 399 

Position  of  the  patient  during  examination,  399  ;  inspection,  399  ;  shape  of 
the  chest,  400  ;  movements  in  respiration,  400  ;  retraction  of  the  chest, 
400  ;  enlargement,  401  ;  palpation,  401  ;  vocal  fremitus,  40l  ;  friction 
fremitus,  401  ;  site  of  apex-beat  of  heart,  401  ;  causes  of  its  disi^lacement,  . 
402  ;  level  of  the  liver  and  spleen,  402  ;  percussion,  402  ;  degree  of  re- 
sistance, 403  ;  auscultation,  403  ;  conduction  of  sounds,  404. 

CHAPTER  n. 
Lakyngitis t •. 406 

Simple  laryngitis,  406  ;  causation,  406  ;  morbid  anatomy,  406  ;  mild  form, 
407  ;  severe  form,  407  ;  illustrative  case,  408  ;  chronic  laryngitis,  408  ; 
diagnosis,  408  ;  case  of  hysterical  aphonia,  409  ;  25rognosis,  410  ;  treat- 
ment, 410  ;  stridulous  laryngitis,  411  ;  causation,  411  ;  morbid  anatomy, 

411  ;  symptoms,  412  ;  dyspno?a,  412  ;  croupy  cough,  412  ;  temperature, 

412  ;  illustrative  case,  412  ;  carpo-pedal  contractions,  413  ;  diagnosis,  413  ; 
prognosis,  414  ;  treatment,  414  ;  tubercular  lai'vngitis,  415  ;  causation, 
415  ;  symptoms,  416  ;  illustrative  case,  416  ;  diagnosis,  417  ;  case  of 
warty  growths  on  larynx,  417  ;  prognosis,  418  ;  treatment,  418. 


CONTENTS.  XV 

CHAPTER  III. 

PAGE 

Suppuration  about  the  LaPvYnx 419 

Causation,  419  ;  morbid  anatomy,  419  ;  symptoms,  419  ;  ortliopnoea,  419  ;  sup- 
pressed voice,  420  ;  diagnosis,  420  ;  prognosis,  421  ;  treatment,  421. 

CHAPTER  IV. 

Croupous  Pneumonia.  , 422 

Causation,  422  ;  nature  of  the  disease,  422  ;  sometimes  secondary,  42o  ;  mor- 
bid anatomy,  423  ;  symptoms,  424  ;  onset,  424  ;  temperature,  424  ;  cough, 
424  ;  muscular  weakness,  425  ;  nervous  symptoms,  425  ;  illustrative  case, 
426  ;  breathing,  426  ;  pulse-respiration  ratio,  426  ;  digestive  organs,  426  ; 
urine,  426  ;  pyrexia,  426  ;  occasional  dyspnoaa,  427  ;  physical  signs,  427  ; 
their  seat,  428  ;  terminations,  428  ;  resolvition,  428  ;  abscess  of  the  lung, 

429  ;  latent  form  of  pneumonia,  429  ;  complications,  430  ;  plastic  pleurisy, 

430  ;  pericarditis,  430  ;  jaundice,  430  ;  diagnosis-  430  ;  prognosis,  431  ; 
treatment,  432  ;  diet,  432  ;  reduction  of  pyrexia,  432  ;  tepid  bathing,  432  ; 
quinine,  432  ;  value  of  bleeding,  433  ;  stimvrlants,  433= 

CHAPTER  V. 

Catarrhal  Pneumonia 434 

Causation,  434  ;  morbid  anatomy,  434  ;  symptoms,  436  ;  always  secondary  to 
pulmonary  catarrh,  436  ;  temperature,  436  ;  pulse-respiration  ratio,  437  ; 
breathing,  437  ;  cough,  437  ;  physical  signs,  437  ;  terminations,  438  ;  sub- 
acute course,  438  ;  complications,  439  ;  diagnosis,  439  ;  from  croupous 
pneumonia,  440 ;  exclusion  of  tuberculosis,  440  ;  acute  dilatation  of 
bronchi,  441  ;  prognosis,  441  ;  treatment,  441  ;  tepid  bathing,  441  ; 
counter-irritation  of  chest,  442  ;  stimulants,  442  ;  diet,  442  ;  emetics, 
442  ;  iron,  443. 

CHAPTER  VI. 

Pleurisy 444 

Causation,  444  ;  morbid  anatomy,  444  ;  characters  of  effusion,  445  ;  symptoms, 
445  ;  onset,  445  ;  pyrexia,  446  ;  pain,  446  ;  complexion,  446  ;  empyema, 
447  ;  physical  signs,  447  ;  inspection,  447  ;  percussion,  448  ;  auscultation, 
449  ;  friction-sound,  449  ;  occasional  symptoms,  449  ;  spontaneous  evacu- 
ation, 450  ;  perforation  of  bronchus,  450  ;  illustrative  case,  451  ;  varieties, 
451  ;  plastic  pleurisy,  452  ;  loculated  form,  452  ;  tuberculous  form,  452  ; 
complications,  453  ;  diagnosis,  453  ;  from  croupous  pneumonia,  453  ; 
from  catarrhal  pneumonia,  454  ;  from  collapse  of  lung,  454  ;  of  empyema, 
455  ;  of  hydrothorax,  455  ;  prognosis,  455  ;  treatment,  456  ;  iodide  of 
potassium,  456  ;  aspiration,  457  ;  illustrative  case,  457  ;  causes  of  siidden 
death,  458  ;  use  of  the  drainage-tube,-  459  ;  resection  of  rib,  460;  diet, 
460. 

CHAPTER  VII. 

Collapse  of  the  Lung , 461 

Two  varieties,  461  ;  congenital  atelectasis,  461  ;  morbid  anatomy,  461  ;  symp- 
toms. 462  ;  prostration,  462  ;  lividity,  462  ;  temperature,  463  ;  feeble  res- 
piration, 462  ;  trifling  physical  signs,  462  ;  drowsiness,  462  ;  signs  of  re- 
covery sometimes  deceptive,  463  ;  diagnosis,  463  ;  prognosis,  463  ;  treat- 
ment, 463  ;  artificial  respiration,  464.;  hot  bath,  464  ;  counter-irritation, 
464  ;  stimulants,  464  ;  post-natal  atelectasis,  465  ;  causation,  465  ;  morbid 
anatomy,  466  ;  symptoms,  467  ;  lividity,  467  ;  feeble,  rapid  breathing, 
467  ;  temperature,  subnormal,  467  ;  perverted  pulse-respiration  ratio, 
467  ;  physical  signs,  467  ;  symptoms  during  second  year,  468  ;  illustra- 
tive case,  469  ;  diagnosis,  469  ;  prognosis,  471  ;  treatment,  471  ;  warmth, 
471  ;  emetics,  471  ;  stimulants,  471. 


XVI  CONTENTS. 


CHAPTER  VIII. 


PAGE 

Fibroid  Indukation  of  the  Lung 473 

Pathology,  473  •,  morbid  anatomy,  474  ;  amyloid  degenerations,  475  ;  symp- 
toms, 475  ;  early  stage,  475  ;  physical  signs  of  established  disease,  476  ; 
symptoms,  476  ;  cough,  476  ;  offensive  sputum,  477  ;  nutrition,  477  ; 
temperature,  477  ;  hypertrophy  of  right  ventricle  of  heart,  477  ;  contrac- 
tion of  side,  477  ;  fibroid  phthisis,  477  ;  diagnosis,  478  ;  from  pleurisy 
with  retraction,  478  ;  from  phthisis,  478  ;  prognosis,  479  ;  treatment, 
479  ;  diet,  479  ;  tonics,  480. 

CHAPTER  IX. 

Bronchitis 481 

Causation,  481  ;  morbid  anatomy,  482  ;  symptoms,  482  ;  of  bronchial  catarrh, 
483  ;  the  mild  form,  483  ;  the  severe  form,  483  ;  capillary  bronchitis, 
483  ;  temperature,  483  ;  dyspnoea,  483  ;  pulse,  484  ;  physical  signs,  484  ; 
signs  of  asphyxia,  484  ;  chronic  bronchitis,  484  ;  symptoms,  485  ;  illustra- 
tive case,  485  ;  diagnosis,  485  ;  prognosis,  486  ;  treatment,  486  ;  counter- 
irritation,  486  ;  diaphoretics,  487  ;  stimulant  expectorants  injurious  at  the 
first,  487  ;  after-treatment,  488  ;  treatment  of  chronic  bronchitis,  489. 


CHAPTER  X. 

Emphysema 491 

Causation,  491  ;  moi-bid  anatomy,  492  ;  two  varieties,  492  ;  inter-lobular  and 
vesicular,  493  ;  symptoms,  only  present  in  the  vesicular  form,  493  ;  phys- 
ical signs,  493  ;  illustrative  cases,  494  ;  diagnosis,  494  ;  prognosis,  494; 
treatment,  495. 

CHAPTER  XI. 

Oangrene  of  the  Lung 496 

Rarity  in  childhood,  496  ;  causation,  496  ;  morbid  anatomy,  497  ;  symptoms, 
497  ;  onset,  gradual  or  sudden,  498  ;  prostration  and  restlessness,  498  ; 
pulse,  498  ;  respiration,  498  ;  temperature,  498  ;  fetid  breath  and  expec- 
toration, 498  ;  dyspnoBa,  498  ;  haemoptysis,  499  ;  physical  signs,  499  ;  il- 
lustrative case,  499  ;  diagnosis,  499  ;  prognosis,  500  ;  treatment,  500  ; 
antiseptic  inhalations,  500  ;  stimulants,  501  ;  diet,  501. 

CHAPTER  XII. 
Pulmonary  Phthisis 502 

Varieties,  502  ;  causation,  502  ;  communicability  of  the  disease,  503  ;  morbid 
anatomy,  504  ;  acute  phthisis,  505  ;  symptoms,  505  ;  dyspnoea,  506  ;  tem- 
perature, 506  ;  physical  signs,  506  ;  illustrative  case,  506  ;  mode  of  death, 
507  ;  duration,  507  ;  prognosis,  507  ;  chronic  pneumonic  phthisis,  508  ; 
mode  of  beginning,  509  ;  stage  of  softening,  509  ;  cough,  509  ;  haemopty- 
sis, 510  ;  temperature,  510  ;   physical  signs,  510  ;    ulceration  of  bowels, 

510  ;  secondary  catarrhal  pneumonia,  510  ;  mode  of  death,  511  ;  chronic 
tubercular  phthisis,  511  ;  wasting,  511  ;  temperature,  511  ;  physical  signs, 

511  ;  advantages  of  removing  diseased  bone,  512  ;  illustrative  case,  512  ; 
occasional  obscurity  of  physical  signs,  513  ;  diagnosis,  513  ;  of  dilated 
bronchi,  514  ;  from  empyema,  514  ;  prognosis,  515  ;  treatment,  516  ;  pre- 
ventive treatment,  516  ;  treatment  of  acute  phthisis,  516  ;  reduction  of 
temperature,  516  ;  regular  feeding,  517  ;  treatment  of  chronic  phthisis, 
517  ;  diet,  517  ;  change  of  air,  517  ;  antiseptic  inhalations,  518  ;  sedatives 
and  expectorants,  518  ;  necessity  of  attention  to  the  digestive  organs,  518. 


CONTEISTTS.  XVll 

CHAPTER  XIII.  PAGE 

Paroxysmal  Dyspncea 519 

Definition  of  dyspnoea,  519  ;  causes  which  produce  it,  519  ;  obstruction  of 
wind-pipe,  519  ;  of  pulmonary  artery,  519  ;  disease  of  heart,  519  ;  ex- 
ternal pressure  upon  lung,  519  ;  by  fluid  in  pleura,  519  ;  by  the  atmos- 
phere in  rickets,  519  ;  disease  of  lung,  519  ;  causes  of  paroxysmal  dysp- 
noea, 520  ;  bronchial  asthma,  520  ;  its  causes,  520  ;  its  symptoms,  521  ; 
its  physical  signs,  521  ;  diagnosis,  521  ;  of  enlarged  bronchial  glands,  522  ; 
of  foreign  body  in  the  air-tubes,  523  ;  of  bronchial  asthma,  523  ;  prog- 
nosis, 524  ;  treatment,  524. 

CHAPTER  XIV. 

Foreign  Bodies  in  the  Air-tubes 526 

Morbid  anatomy,  526  ;  symptoms,  527  ;  dyspnoea,  527  ;  spasmodic  cough, 
527  ;  pain  in  the  chest,  528  ;  physical  signs,  528  ;  spontaneous  expulsion, 
529  ;  gangrene  of  lung,  529  ;  illustrative  case,  529  ;  seat  of  the  foreign 
body,  530  ;  in  the  larynx,  530  ;  in  the  trachea,  531  ;  in  the  bronchus, 
531  ;  diagnosis,  531  ;  from  spasmodic  laryngitis,  532  ;  from  membranous 
croup,  533  ;  prognosis,  533  ;  treatment,  533. 


|3art  7. 
DISEASES   OF  THE  HEAKT. 

CHAPTER  I. 

Congenital  Heart  Disease 535 

«  Normal  development  of  the  heart,  535  ;  arrest  of  development,  536  ;  varieties 
of  malformation,  536  ;  morbid  anatomy,  537  ;  symptoms,  538  ;  cyanosis, 
5-38  ;  shape  of  chest,  538  ;  temperature,  538  ;  dyspnoea,  538  ;  oedema, 
538  ;  urine,  539  ;  digestive  organs,  539  ;  the  commonest  form  of  mal- 
formation, 539  ;  nutrition,  539  ;  disease  of  the  petrous  bone,  540  ;  con- 
vulsions, 540  ;  duration  of  life,  540  ;  mode  of  death,  540  ;  diagnosis,  540; 
prognosis,  542  ;  treatment,  542. 

CHAPTER  II. 

Ohronic  Valvular  Disease  of  the  Heart 544 

Causation,  544  ;  rheumatism,  544  ;  chorea,  544  ;  syphilis,  545  ;  morbid  anat- 
omy, 545  ;  valvular  lesions,  545  ;  adhesion  of  pericardium,  546  ;  Par- 
rot's h^matomata,  546 ;  hypertrophy  and  dilatation  of  walls,  546  ; 
symptoms,  547 ;  dyspncea,  547 ;  palpitation,  547  ;  haemorrhages,  547 ; 
embolisms,  547  ;  of  brain,  548  ;  illustrative  case,  548  ;  symptoms  due  to 
the  rheumatic  disposition,  549  ;  impairment  of  nutrition,  549  ;  relative 
frequency  of  the  various  forms,  549  ;  terminations,  550 ;  cardiac  dropsy, 
550  ;  clotting  of  blood  in  the  heart,  550  ;  illustrative  cases,  550  ;  diagno- 
sis, 550 ;  occasional  disappearance  of  murmur,  551  ;  prognosis,  552  ; 
treatment,  552  ;  digitalis,  553  ;  aperients,  553  ;  diet,  553  ;  diuretics,  553. 


|3art  8. 
DISEASES   OF  THE  MOUTH  AND   TIIKOAT. 

CHAPTER  I. 

The  Derangements  of  Teething 555 

Teething  not  a  morbid  process,  555  ;  eruption  of  the  milk-teeth,  556  ;  natural 
order,  557  ;  irregularities,  557 ;  symptoms  of  teething,  558  ;  temperature. 


XVm  CONTET^TS. 


558  ;  complications,  558  ;  stomatitis,  559  ;  digestive  troubles,  559  ;  pul- 
monary catarrh,  559  ;  otitis,  560  ;  skin  diseases,  560 ;  nervous  disorders, 
560  ;  the  second  dentition,  560 ;  order  of  eruption,  560  ;  diagnosis,  561  ; 
treatment,  561;  value  of  lancing  the  gums,  563;  treatment  of  "night 
terrors,"  562. 

CHAPTER  n. 

Stomatitis 563- 

Aphthous  stomatitis,  563  ;  symptoms,  563 ;  diagnosis,  564  ;  prognosis,  564 ; 
treatment,  564.  Ulcerative  stomatitis,  564 ;  causation,  564 ;  symptoms, 
565  ;  diagnosis,  566  ;  prognosis,  566  ;  treatment,  566 ;  value  of  chlorate 
of  potash,  566. 

CHAPTER  in. 

Gangrenous  Stomatitis 567 

Causation,  567  ;  morbid  anatomy,  567 ;  symptoms,  568  ;  duration,  569  ;  prog- 
nosis, 569  ;  treatment,  569  ;  diet  and  stimulants,  569  ;  caustics,  570  ; 
quinine  and  iron,  570. 

CHAPTER  IV. 

Thrush 571 

Causation,  571  ;  morbid  anatomy,  572 ;  the  oidium  albicans,  572  ;  its  seat, 
572  ;  symptoms,  573  ;  in  mild  cases,  573  ;  in  severe  cases,  573  ;  local 
symptoms,  573  ;  general  symptoms,  573  ;  diagnosis,  574  ;  prognosis,  574 ; 
treatment,  574. 

CHAPTER  V. 

Pharyngitis 576 

Simple  pharyngeal  catarrh,  576  ;  causation,  576  ;  symptoms,  576  ;  scald  of 
throat,  577 ;  diagnosis,  577  ;  treatment,  577 ;  of  scald,  578.  Follicular 
pharyngitis,  578  ;  causation,  578  ;  morbid  anatomy,  578  ;  symptoms,  578  ; 
deafness,  579  ;  appearance  of  fauces,  579  ;  diagnosis,  579  ;  prognosis,  579  ; 
treatment,  579  ;  local  applications,  580  ;  caustics,  580.  Herpes  of  the 
pharynx,  580;  causation,  580;  symptoms,  580;  diagnosis,  580;  treat- 
ment, 581.  Tubercular  pharyngitis,  581 ;  morbid  anatomy,  581 ;  s^'mp- 
toms,  581 ;  appearance  of  fauces,  581  ;  ulceration  of  throat,  582  ;  often 
extensive,  582  ;  temperature,  582  ;  pain  in  swallowing,  582  ;  implication 
of  lungs,  582  ;  diagnosis,  582  ;  from  syphilitic  ulceration,  582  ;  prognosis, 
583  ;  treatment,  583. 

CHAPTER  VL 

QumsY. 584 

Nature  of  the  disease,  584  ;  causation,  584  ;  morbid  anatomy,  585  ;  symptoms, 
585;  pain,  585  ;  temperature,  585';  formation  of  abscess,  586  ;  duration,  - 
586  ;  the  non-suppurative  form,  566  ;  chronic  enlargement  of  tonsils,  586  ; 
their  influence  on  the  general  health,  587  ;  alteration  of  features,  587  ;  de- 
formity of  chest,  587  ;  cough,  588  ;  diagnosis,  588  ;  prognosis,  588  ;  treat- 
ment, 588 ;  aconite,  588  ;  salicylate  of  soda,  588  ;  local  applications,  589  ; 
diet,  589  ;  treatment  of  chronic  enlargement,  589  ;  excision,  590  ;  caus- 
tics, 590. 

CHAPTER  VII. 

Retro-phaiiyngeal  Abscess 591 

Causation,  591 ;  morbid  anatomy,  591  ;  symptoms,  592  ;  dysphagia,  592  ; 
dyspnoea,  592  ;  cough,  592  ;  acute  form,  593  ;  chronic  form,  •j93  ;  illus- 
trative case,  593  ;  terminations,  594  ;  diagnosis,  594  ;  from  membranous 
croup,  594  ;  from  oedema  of  glottis,  594  ;  prognosis,  595  ;  treatment,  595. 


co]srTE]S"TS.  xix 

|3avt  9. 
DISEASES   OF  THE  DIGESTIVE   ORGANS. 

CHAPTER  I. 

PAGE  . 

Infantile  Atrophy 596 

Causation,  596  ;  due  to  insufficient  nourishment,  596  ;  cow's  milk  often  indi- 
gestible, 597  ;  reason  of  this,  597  ;  analysis  of  various  milks,  597  ;  diffi- 
culty of  digesting  starch  in  early  infancy,  598  ;  liability  to  catarrh  in 
early  life,  598  ;  occasional  indigestibility  of  breast-milk,  599  ;  illustrative 
case,  599  ;  morbid  anatomy  of  atrophy,  600  ;  symptoms,  600  ;  wasting, 
600  ;  signs  of  indigestion,  600  ;  eruptions  on  the  skin,  601  ;  colic,  601  ; 
constipation,  601  ;  vomiting,  601  ;  diarrhcsa,  602  ;  diagnosis,  602 ;  from 
infantile  syphilis,  602  ;  from  acute  tuberculosis,  602  ;  prognosis,  603  ; 
treatment,  603  ;  rules  for  the  hand-feeding  of  infants,  604  ;  preparation 
of  cow's  milk,  606  ;  pancreatised  milk,  606  ;  artificial  human  milk,  606  ; 
treatment  of  obstinate  vomiting,  607  :  illustrative  cases,  607  ;  necessity  of 
vigilance,  608. 

CHAPTER  II. 
Gastric  Catarrh , 609 

Causation,  609  ;  morbid  anatomy,  610  ;  symptoms,  610  ;  acute  febrile  form, 

610  ;  temperature,  610  ;  signs  of  general  catarrh,  610  ;  recurring  attacks, 

611  ;  their  influence  upon  general  nutrition,  611  ;  the  non-febrile  variety, 
611  ;  sallow  complexion,  611  ;  languor,  611 ;  flatulence,  611  ;  nervous 
movements,  611 ;  headache,  611  ;  uric  acid  and  urates  in  urine,  611  ; 
tongue,  612  ;  fainting  fits,  612  ;  diagnosis,  612  ;  illustrative  cases,  613  ; 
treatment,  615 ;  diet,  615  ;  tonics,  615  ;  warmth  to  the  belly,  616  ;  baths, 
616. 

CHAPTER  III. 
Constipation 617 

Causation,  617  ;  symptoms,  619  ;  in  infants,  619  ;  in  older  children,  619  ;  im- 
paction of  fseces,  619  ;  may  prove  fatal,  620  ;  diagnosis,  620  ;  treatment, 
621  ;  in  infants,  621  ;  aperients,  621  ;  pepsin,  622  ;  enemata,  622  ;  treat- 
ment of  colic,  622  ;  in  older  children,  623  ;  treatment  of  impaction  of 
fseces,  623. 

CHAPTER  IV. 

DiARRHCEA 624 

Varieties,  624  ;  causation  of  simple  diarrhoea,  624  ;  morbid  anatomy,  625  ; 
symptoms,  625  ;  character  of  the  stools,  626  ;  lienteric  diarrhoea,  626  ; 
treatment,  626  ;  of  lienteric  diarrhoea,  628. 

CHAPTER  V. 

iNFIiAMMATORY    DIARRHOEA 629 

Causation,  629  ;  morbid  anatomy,  630  ;  symptoms,  630  ;  in  infants,  630  ;  char- 
acter of  stools,  630  ;  frequency  of  motions,  631  ;  their  microscopic  appeai- 
ances,  631  ;  general  symptoms,  631  ;  temperature,  631  ;  illustrative  cases, 

631  ;  catarrh  of  colon,  631  ;  tenesmus,  632  ;  blood  in  stools,  632  ;  com- 
plications, 632  ;  parenchymatous  nephritis,  632  ;  spurious  hydrocephalus, 

632  ;  in  children  after  infancy,  632  ;  general  symptoms,  632  ;  tempera- 
ture, 633  ;  the  urine,  633  ;  early  prostration,  633  ;  the  chronic  form,  633  ; 
insidious  beginning,  633  ;  pasty  stools,  633  ;  gradual  wasting,  633  ;  diar- 
rhoea, 634  ;  oedema,  634  ;  diagnosis,  634  ;  of  seat  of  catarrh,  634  ;  Professor 
Notlinagel's  researches,  634  ;  prognosis,  635  ;  treatment,  636  ;  diet,  636  ; 
warmth,  636  ;  ventilation,  636  ;  cold  or  tepid  bathing,  637  ;  illustrative 
case,  637  ;  remedies,  637  ;  value  of  astringents,  638  ;  of  ipecacuanha,  638  ; 
of  opium,  638  ;  treatment  of  acute  prolapsus  ani,  639  ;  of  spurious  hydro- 
cephalus, 639  ;  of  chronic  diarrhoea,  640  ;  value  of  raw  meat,  640. 


XX  CONTENTS. 

CHAPTER  VI. 

PAGB 

Choleraic  Diarrhcea  (Infantile  Cholera) 643 

Causation,  642  ;  morbid  anatomy,  642  ;  symptoms,  642  ;  vomiting,  643  ;  diar- 
rhoea, 643  ;  character  of  stools,  643  ;  rapid  wasting,  643  ;  excessive  thirst, 
643  ;  temperature,  643  ;  exhaustion,  644  ;  occasional  recovery,  644  ;  dura- 
tion, 644  ;  diagnosis,  644  ;  prognosis,  644  ;  treatment,  644  ;  abundant 
liquid,  644  ;  food,  644  ;  koumiss,  644  ;  white  wine  whey,  645  ;  drugs, 
645  ;  hypodermic  injection  of  morphia,  645  ;  illustrative  case,  646. 

CHAPTER  VII. 

Dysentery 647 

Causation,  647  ;  morbid  anatomy,  647  ;  sloughing  of  mucous  membrane,  648  ; 
abscesses  in  liver,  648  ;  symptoms,  648  ;  tenesmus,  648  ;  mucus,  648 ; 
blood,  648  ;  colic,  649  ;  chai-acterof  stools,  649  ;  their  offensive  odour,  649  ; 
temperature,  650  ;  mode  of  death,  650  ;  chronic  form,  650  ;  diagnosis, 
650  ;  prognosis,  651  ;  treatment,  651  ;  value  of  opium,  651  ;  of  ipecacu- 
anha, 651  ;  of  mercury,  652  ;  special  treatment  for  infants,  652  ;  astrin- 
gent injections,  653  ;  diet,  653  ;  treatment  of  the  chronic  form,  653 ;  diet 
during  convalescence,  653. 

CHAPTER  Vni. 

Castro-intestinal  Hemorrhage 654 

Spurious  hgematemesis,  654 ;  its  causes,  654  ;  causes  of  the  real  haemorrhage, 
654  ;  melsena  neonatorum,  654  ;  its  causes,  655  ;  hemorrhage  in  older 
children,  655  ;  causes,  655  ;  general,  655  ;  local,  655  ;  polypus  of  rectum, 

656  ;  symptoms  of  gastro-intestinal  hfemorrhage,  656  ;  of  melsena  neona- 
torum, 656  ;  of  haemorrhage  in  later  childhood,  657  ;  of  polypus  of  rectum, 

657  ;  diagnosis,  657  ;  prognosis,  658  ;  treatment,  659. 

CHAPTER  IX. 

Ulceration  of  the  Bowels 660 

Varieties  of  ulcer,  660  ;  morbid  anatomy,  660  ;  symptoms,  661  ;  often  obscure, 
661  ;  pain  in  abdomen,  661  ;  tenderness,  661  ;  tension  of  parietes,  661  ; 
the  stools,  662  ;  haemorrhage,  662  ;  state  of  nutrition,  662  ;  complications, 
663  ;  illustrative  case,  663  ;  diagnosis,  664  ;  of  nature  of  ulceration,  665  ; 
prognosis,  665  ;  treatment,  666  ;  diet,  666  ;  value  of  raw  meat,  666  ;  of 
malted  bread,  666  ;  milk  inadmissible,  666  ;  stimulants,  667  ;  drugs,  667  ; 
nitrate  of  silver,  667  ;  opium,  667 ;  astringent  injections,  667  ;  pepsin, 
667. 

CHAPTER  X. 

Intestinal  Obstruction  (Intussusception) 668 

Varieties  of  obstruction,  668  ;  intussusception,  668  ;  causation,  668  ;  morbid 
anatomy,   668  ;  symptoms,   670  ;  in  infants,  670  ;   pain,  670 ;   straining, 

670  ;  discharge  of  blood,  670  ;  constipation,  670  ;  temperature,  670  ;  col- 
lapse, 671  ;  in  older  children,  671  ;  distention  of  belly,  671  ;  vomiting, 

671  ;  melsena  not  always  present,  671  ;  signs  of  prostration,  671  ;  separa- 
tion of  gangrenous  segment,  672  ;  mode  of  death,  672  ;  special  symptoms, 

672  ;  swelling  in  the  abdomen,  673  ;  temperature,  673 ;  duration,  673  ; 
diagnosis,  673  ;  from  simple  colic,  674  ;  from  peritonitis,  674 ;  from  dys- 
entery, 674 ;  from  impaction  of  faecal  matter,  675 ;  prognosis,  675  ;  treat- 
ment, 675  ;  injections  of  water,  676  ;  insufflation  of  air,  676  ;  taxis,  676  ; 
surgical  interference,  677. 


CONTENTS.  XXi 

CHAPTER  XI. 

PAGE 

Typhxitis  and  Pekityphlitis 678 

Causation,  678  ;  symptoms,  679  ;  of  typhlitis,  679  ;  of  perityphlitis,  679  ;  per- 
foration of  bowel,  679  ;  extravasation  into  peritoneum,  679  ;  suppuration 
behind  csecum,  680 ;  simulation  of  hip-joint  disease,  680  ;  post-caecal  ab- 
scess, 680  ;  illustrative  case,  681  ;  perforation  of  vermiform  appendix, 
682  ;  diagnosis,  682  ;  of  typhlitis,  682  ;  of  perityphlitis,  683  ;  of  perfora- 
tion of  the  vermiform  process,  683 ;  prognosis,  683 ;  treatment,  684 ; 
aperients  hurtful,  684  ;  diet,  684. 

CHAPTER  XII. 

Acute  Peritonitis. 685. 

Causation,  685  ;  morbid  anatomy,  686  ;  symptoms,  686  ;  of  the  primary  form, 
686  ;  vomiting,  687 ;  pain  and  tenderness,  687  ;  temperature,  687  ;  dis- 
tention of  belly,  687  ;  fluctuation,  687 ;  looseness  of  bowels,  687  ;  the 
secondary  form,  688  ;  the  latent  form,  688  ;  diagnosis,  689  ;  from  the 
tuberciilous  form,  689  ;  from  colic,  689  ;  from  rheumatism  of  the  abdom- 
inal wall,  689  ;  visceral  peritonitis,  690 ;  illustrative  case,  690  ;  prognosis, 
691  ;  treatment,  691 ;  opium,  691  ;  leeches,  691  ;  warmth  to  the  belly, 
691  ;  diet,  691  ;  treatment  of  tympanitis,  692. 

CHAPTER  XIII. 

Tubercular  Peritonitis 693 

Morbid  anatomy,  693  ;  symptoms,  694 ;  of  the  chronic  form,  694  ;  insidious 
beginning,  694  ;  illustrative  case,  694  ;  tenderness  of  abdomen,  694 ;  dis- 
tention, 695  ;  unequal  resistance  of  belly,  695  ;  obscure  fluctuation,  695  ; 
temperature,  695  ;  rapid  wasting,  696  ;  occasional  improvement,  696  ; 
the  acute  form,  696  ;  illustrative  case,  696  ;  diagnosis,  697  ;  of  the 
chronic  form,  698  ;  of  acute  form,  698  ;  prognosis,  698  ;  treatment,  698  ; 
warmth  to  belly,  698  ;  opium,  699  ;  of  the  diarrhoea,  699  ;  diet,  699. 

CHAPTER  XIV. 

Ascites 700 

Causation,  700  ;  symptoms,  700  ;  distention  of  belly,  700  ;  fluctuation,  701  ; 
percussion  dulness  in  flanks,  701  ;  occasional  dyspnoea,  701 ;  other  symp- 
toms according  to  cause,  701  ;  diagnosis,  702  ;  illustrative  case,  702 ;  from 
hydronephrosis,  703  ;  prognosis,  703  ;  treatment,  704  ;  paracentesis,  704. 

CHAPTER  XV. 

Intestinal,  Worms 705 

Varieties,  705  ;  description,  706  ;  mode  of  entrance  into  body,  707  ;  symp- 
toms, general,  708  ;  special,  of  thread-worms,  709  ;  of  lumbrici,  709  ; 
nocturnal  diarrhoea,  710  ;  their  migrations,  710  ;  of  tape-worm,  711  ;  di- 
agnosis, 711  ;  treatment,  711  ;  of  thread-worms,  711  ;  of  lumbrici,  712  ; 
of  tape-worm,  712  ;  various  vermifuges,  712. 


|3art  la. 

DISEASES   OF  THE  LIYEE. 

CHAPTER  I. 
Jaundice 714 

In  infants  (icterus  neonatorum),  714  ;  true  and  false  jaundice,  714  ;  symp- 
toms of  icterus,  715  ;  cavises,  716  ;  from  congenital  malformation  of  bile- 
ducts,  716  ;  cirrhosis  of  liver,  717  ;  haemorrhage  from  navel,  717  ;  illus- 


XXU  CONTENTS. 

PAGE 

trative  case,  718  ;  from  syphilitic  inflammation  of  the  liver,  718  ;  from 
umbilical  phlebitis  (icterus  malignus),  718  ;  jaundice  in  childhood,  719  ; 
causes,  719  ;  diagnosis,  719  ;  prognosis,  720  ;  treatment,  720. 

CHAPTER  II. 

-Congestion  of  the  Liver 722 

Causation,  722  ;  morbid  anatomy,  722  ;  symptoms,  723  ;  sense  of  weight  in 
side,  723  ;  dyspeptic  symptoms,  723  ;  light-coloured  stools,  723  ;  diagnosis, 
723  ;  illustrative  case,  724  ;  prognosis,  724  ;  treatment,  724  ;  diet,  724. 

CHAPTER  in. 

Cirrhosis  of  the  Liver 726 

Causation,  726  ;  morbid  anatomy,  726  ;  two  varieties,  726  ;  symptoms,  727  ; 
of  atrophic  cirrhosis,  727  ;  indigestion,  727  ;  ascites,  728  ;  earthy  tint  of 
'         skin,  728  ;  haemorrhages,  728  ;  of  hypertrophic  cirrhosis,  728  ;  jaundice, 
728  ;  enlargement  of  liver,  728  ;   diagnosis,  729  ;  prognosis,  729  ;  treat- 
ment, 730  ;  aperients,  730  ;  paracentesis,  730. 

CHAPTER  IV. 

AivrriiOiD  LmsR 731 

Causation,  731  ;  morbid  anatomy,  731  ;  symptoms,  731  ;  enlargement  of  liver, 
731  ;  absence  of  pain  or  tenderness,  732  ;  digestive  disturbance,  732  ; 
anaemia,  732  ;  oedema,  732  ;  kidneys  and  spleen  often  implicated,  732 ; 
diagnosis,  732  ;  prognosis,  733  ;  occasional  complete  recovery,  733  ;  treat- 
ment, 733 ;  iodine,  733 ;  iron,  733  ;  liberal  diet,  734  ;  sea  air,  734. 

CHAPTER  V. 

Fatty  Liver T35 

Causation,  735  ;  two  forms,  735  ;  morbid  anatomy,  735  ;  symptoms  of  fatty 
infiltration,  735  ;  enlargement,  735  ;  occasional  tenderness,  736  ;  diag- 
nosis, 736  ;  prognosis,  736  ;  treatment,  736. 

CHAPTER  VI. 

Hydatid  op  the  Liver 737 

Causation,  737  ;  morbid  anatomy,  737  ;  description  of  the  tasnia  echinococcus, 
737  ;  symptoms,  738  ;  swelling  in  liver,  739  ;  rarely  jaundice  or  ascites, 
739  ;  illustrative  case,  739  ;  termination  if  left  alone,  740  ;  diagnosis,  740  ; 
prognosis,  741  ;  treatment,  741  ;  paracentesis,  742  ;  illustrative  case,  743  ; 
treatment  by  electrolysis,  742. 


Part  n. 
DISEASES  OF  THE  GENITO-UPJNAEY  OEGAl^S. 

CHAPTER  I. 

The  Urine 744 

Characters  of  the  urine  in  health,  744  ;  variations  in  its  quantity,  744  ;  their 
causes,  745  ;  variations  in  the  quantity  of  solid  matters,  745  ;  of  urea, 
745  ;  causes  of  lithates,  745  ;  albuminuria,  746  ;  its  causes,  746  ;  hsema- 
turia,  746  ;  its  causes,  746  ;  from  irritation  of  the  passages  by  the  bilhar- 
zia  haematobia,  747  ;  retention  of  urine,  748  ;  its  causes,  748  ;  nocturnal 
incontinence  of  urine,  748  ;  its  nature,  749  ;  and  treatment,  750. 


CONTENTS.  xxiii 

CHAPTER  II. 

PAGE 

Chbonic  Bright's  Disease 752 

Causation,  752  ;  morbid  anatomy,  753  ;  the  granular  kidney,  753  ;  the  fatty 
kidney,  753 ;  the  amyloid  kidney,  753  ;  symptoms,  754  ;  illustrative 
case,  754  ;  anaemia,  headache  and  vomiting,  755  ;  acute  exacerbations, 
755  ;  illustrative  case,  755  ;  insidious  progress  of  the  granular  kid- 
ney, 756  ;  illustrative  case,  756  ;  the  amyloid  kidney,  758  ;  renal  inade- 
quacy, 758  ;  sometimes  seen  in  young  infants^  -758  ;  diagnosis  of  renal 
disease,  759  ;  prognosis,  760  ;  treatment,  760  ;  diet,  760  ;  aperients,  761  ; 
especially  valuable  in  uraemia,  761  ;  diaphoretics,  761  ;  iron,  761  ;  treat- 
ment of  chronic  albuminuria,  762. 

CHAPTER  III. 
Calculus  op  the  Kidney 763 

Sand  in  the  urine  common  in  children,  763  ;  formation  of  uric  acid  in  urine, 

763  ;  formation  of  oxalate  of  lime,  764  ;  causation  of  calculus  of  kidney, 

764  ;  symptoms,  764  ;  hsematuria,  765  ;  pain  in  loins,  765  ;  illustrative 
case,  765  ;  renal  colic,  766  ;  impaction  of  stone  in  ureter,  766  ;  stone  in 
bladder,  766  ;  diagnosis  of  calculus  of  kidney,  767  ;  illustrative  case,  767  ; 
prognosis,  768  ;  treatment,  768  ;  diet,  768  ;  alkalis,  768. 

CHAPTER  IV. 

Tumours  of  the  Kidney  .^ 770 

Sarcoma  of  kidney,  770  ;  morbid  anatomy,  770  ;  symptoms,  770  ;  swelling  of 
abdomen,  770  ;  signs  of  pressure,  771  ;  illustrative  case,  771  ;  duration, 
772  ;  hydronephrosis,  772  ;  causation,  772  ;  symptoms,  772  ;  painless 
tumour,  772  ;  fluctuation,  773  ;  diagnosis  of  renal  tumours,  773  ;  treatment 
of  hydronephrosis,  774. 

'  CHAPTER  V. 

Vulvitis 775 

Two  forms,  775  ;  causation,  775  ;  symptoms,  775  ;  of  catarrhal  vulvitis,  775  ; 
of  aphthous  vulvitis,  776  ;  diagnosis,  776  ;  treatment,  776  ;  of  catarrhal 
vulvitis,  776  ;  of  aphthous  vulvitis,  777. 


}})art  12. 
DISEASES   OF   THE    SKIK 

CHAPTER  I. 

Diseases  of  the  Skin 778 

The  papular  eruptions,  778  ;  prurigo,  778  ;  strophulus,  779  ;  vesicular  erup- 
tions, 779  ;  herpes,  779  ;  pemphigus,  779  ;  duration  of  the  spots,  780  ; 
treatment,  780  ;  pustular  eruptions,  780  ;  ecthyma,  780  ;  scaly  eruptions, 
780  ;  psoriasis,  780  ;  value  of  perchloride  of  mercury,  781  ;  alopecia 
areata,  781  ;  treatment,  781. 

CHAPTER  n. 
The  Erythemata. 782 

Erythema  simplex,  782  ;  its  varieties,  782  ;  erythema  fugax,  782  ;  erythema 
papulatum,  782  ;  erythema  intertrigo,  782  ;  the  belladonna  rash,  783  ; 
diagnosis  of  simple  erythema,  783  ;  treatment,  783  ;  erythema  nodosum, 

783  ;   symptoms,  784  ;  illustrative  case,   784  ;  diagnosis,  784  ;  treatment, 

784  ;  urticaria,  785  ;  symptoms,  785  ;  diagnosis,  786  ;  treatment,  786  ;  of 
the  chronic  form,  786  ;  roseola,  786  ;  symptoms,  787  ;  illustrative  case, 
787  ;  diagnosis,  787  ;  treatment,  788. 


XXIV  CONTENTS. 


CHAPTER  in. 

Pkax 

Eczema 789 

Causation,  789  ;  symptoms,  790  ;  varieties,  790  ;  eczema  simplex,  790  ;  eczema 
rubrum,  790  ;  eczema  capitis,  790  ;  impetigo  contagiosa,  791  ;  eczema  tarsi, 
791  ;  eczema  infantile,  791  ;  illustrative  case,  791 ;  diagnosis,  792  ;  treat- 
ment, 792  ;  diet,  793  ;  local  applications,  793  ;  treatment  of  the  varieties, 
794  ;  baths,  795. 

t 

CHAPTER  IV. 

MOLIiUSCUM  CONTAGIOSTJM 796 

Morbid  anatomy,  796  ;  symptoms,  796  ;  diagnosis,  797  ;  treatment,  797. 

CHAPTER  V. 

The  Paeasitic  Diseases 798 

Scabies,  798  ;  the  acarus  scabiei,  798  ;  the  furrow,  798  ;  symptoms,  798  ;  in- 
tense itching,  798  ;  various  rashes,  799  ;  diagnosis,  799  ;  treatment,  799  ; 
tinea  tonsurans,  799  ;  pathology,  799  ;  symptoms,  800  ;  on  the  scalp,  800  ; 
on  the  body  (tinea  circinata),  800  ;  diagnosis,  801 ;  treatment,  801  ;  in  the 
infant,  802  ;  in  older  children,  802  ;  various  applications,  803  ;  tinea 
favosa,  804  ;  symptoms,  804  ;  diagnosis,  805  ;  treatment,  805. 

CHAPTER  VI. 
Sclerema 80& 

Two  diseases  often  confounded  together,  806  ;  true  sclerema,  806  ;  morbid 
anatomy,  806  ;  sclerema  adiposa,  807  ;  symptoms,  807  ;  rigidity  of  skin, 
807  ;  low  temperature,  807  ;  rapid  course,  807  ;  oedema  of  new-born  in- 
fants, 808  ;  symptoms,  808  ;  diagnosis  between  the  two  diseases,  808  ; 
treatment,  809. 


DISEASE  11^  CHILDEEK 


mTRODUCTORY   CHAPTER. 

The  difficulties  connected  with  the  investigation  of  disease  as  it  occui's  in 
early  life  may  be  easily  exaggerated.  The  subject  is  no  doubt  a  special 
one  ;  but  when  the  first  strangeness  has  been  overcome  of  dealing  with 
patients  who  cannot  describe  their  sensations,  and  who  show  their  distress 
by  cries  and  gestiu-es  which  it  requires  experience  to  be  able  to  interpret, 
the  chief  obstacle  to  progress  has  been  surmounted.  All  necessary  infor- 
mation as  to  the  onset  and  early  symptoms  of  the  complaint  can  usually  be 
obtained  from  the  mother.  Most  women  are  good  observers.  Affection 
and  anxiety  increase  their  watchfulness,  and  make  them  fairly  accurate  re- 
corders of  every  outward  change.  The  stress  laid  by  them  upon  particu- 
lar phenomena  is  not,  indeed,  always  a  true  measure  of  the  real  impor- 
tance of  the  symptoms  ;  but  it  is  easy  to  correct  any  undue  emphasis  in 
the  naiTative  by  our  own  judgment  and  experience.  Still,  we  must  guard 
ourselves  from  being  misled  by  the  very  fulness  of  the  report :  facts  may  be 
accepted  with  coniidence,  but  volunteered  explanation  of  these  facts  must 
on  no  account  be  allowed  to  influence  our  conclusions. 

"VVTien  called  to  a  sick  child  our  first  care  should  be  to  give  an  attentive 
hearing  to  the  statement  of  the  mother,  supplying  any  gaps  in  the  history 
by  suitable  questions.  Having  thus  been  enlightened  as  to  the  previous 
health  of  the  child  and  the  nature  of  the  earhest  symptoms,  we  have  next 
to  collect  what  information  we  can  from  the  appearance  and  manner  of  the 
patient.  To  do  this  with  success  we  must  possess  already  a  certain  famil- 
iarity with  the  ways  of  infants  and  young  children  ;  but  this  is  easily  ac- 
quired with  a  little  practice.  Again,  we  have  so  to  regulate  our  own  iDear- 
ing  as  not  to  alarm  the  child,  who  is  ah*eady  perhaps  in  a  state  of  disquiet. 
It  has  been  said  that  a  natural  fondness  for  children  is  indispensable  to 
success  in  this  branch  of  medicine  ;  but  this  is  an  exaggeration.  A  quiet, 
genial  manner  with  a  jDleasant  smile  and  a  gentle  voice  will  soon  dissipate 
the  apprehensions  of  the  patient  and  gain  his  confidence.  Lastly,  Ave  pro- 
ceed to  a  physical  examination  of  the  various  organs.  This,  if  done  de- 
liberately and  without  abruptness  or  hui'ry,  can  be  effected  in  most  cases 
without  much  trouble. 

The  main  difficulty  in  the  diagnosis  of  disease  in  early  life  arises;  not 
from  the  absence  of  intelHgent  sjDeech  on  the  part  of  the  patient,  nor  from 
any  uncertainty  in  the  recognition  of  visible  signs  of  suffering.  It  springs 
from  the  perplexity  we  often  feel  in  referring  these  sj^mj^toms  to  their  true 
origin.  Children  are  not  merely  little  men  and  women  in  whose  bodies 
1 


2  DISEASE  IN"   CHILDEEN. 

disease  manifests  itself  by  exactly  the  same  tokens  that  are  familiar  to  us 
in  the  ease  of  the  adult.  They  have  special  constitutional  peculiarities 
which  give  to  disease  in  early  life  a  character  it  does  not  afterwards  retain, 
and  invest  the  commonest  forms  of  illness  with  strange  features  which 
may  be  a  source  of  obscurity  and  confusion.  The  most  striking  peculi- 
arity of  childhood  is  a  marked  excitabihty  of  the  nervous  system — an  ex- 
cess of  sensitiveness  which  any  deviation  from  the  healthy  state  brings  at 
once  into  prominence.  Consequently,  a  frmctional  derangement  which  in 
the  adult  would  give  rise  merely  to  shght  local  symptoms,  in  the  child 
may  be  accompanied  by  signs  of  severe  general  distress  ;  and  the  indica- 
tions of  local  suffering  may  be  thus  overshadowed  or  completely  concealed. 
A  common  example  of  this  nervous  excitabihty  is  seen  in  the  distui'bance 
which  often  results  from  swaUowing  some  indigestible  article  of  food.  The 
skin  becomes  burning  hot,  the  child  is  in  a  state  of  extreme  agitation,  is 
perhaps  convulsed,  or  lies  in  a  state  of  stupor  from  which  he  can  with  dif- 
ficulty be  roused.  In  such  a  case  the  state  of  the  stomach  is  apt  to  be 
overlooked  ;  for  even  if  the  child  vomit,  which  does  not  always  happen, 
the  symptom  may  pass  almost  unnoticed  as  one  of  the  consequences  of 
the  general  nervous  perturbation.  General  symptoms  of  a  like  character 
may  accompany  the  onset  of  any  acute  illness,  and  their  severity  bears  no 
relation  to  the  importance  of  the  ailment  of  which  they  are  a  consequence. 
As  j)i'ofound  a  disturbance  may  be  excited  by  the  simplest  functional  de- 
rangement as  by  the  severest  organic  malady  ;  so  that  to  the  eye  ac- 
customed to  the  orderly  progTCSS  of  disease  in  the  adult  symptoms  seem  to 
have  lost  their  value  and  to  be  calculated  rather  to  mislead  than  to  inform. 
This  excitability  of  the  neiwous  system  in  early  life  is  a  pecuharity  which 
must  be  taken  into  account  in  every  case  of  acute  illness  ;  and  we  must 
endeavour  to  separate  the  local  symptoms — those  which  point  to  mischief 
of  a  sj)ecial  organ — from  others  which  are  merely  the  expression  of  the 
general  distress.  Such  local  symptoms  are  the  cough,  rapid  breathing, 
and  active  nares  which  point  to  acute  lung  disease,  the  squinting  and  im- 
mobility of  pupils  which  are  so  characteristic  of  cerebral  affections,  and 
the  peculiar  jerking  movement  of  the  legs  which,  combined  with  hardness 
of  the  abdominal  muscles,  betray  the  existence  of  colicky  pain. 

Local  symptoms  are  not,  however,  to  be  discovered  in  every  case,  and 
even  if  present  cannot  always  be  relied  upon  to  furnish  trustworthy  indi- 
cations. Owing  to  the  exaggerated  impressibility  of  the  nervous  system 
a  peculiar  sympathy  exists  between  the  various  organs.  Consequently, 
symptoms  induced  by  irritation  in  any  part  of  the  body  are  seldom  limited 
to  the  part  actually  affected.  Signs  of  distress  arise  at  the  same  time 
from  other  and  distant  organs  ;  indeed,  the  organ  from  which  the  more  defi- 
nite symptoms  appear  to  arise  is  often  not  the  organ  which  is  the  actual 
seat  of  disease.  These  deceptive  manifestations  are  most  frequently  no- 
ticed in  the  case  of  the  stomach  and  the  brain.  In  the  case  of  the  stomach 
the  response  excited  in  this  organ  by  in-itation  in  distant  j)arts  of  the  body 
persists  more  or  less  through  life.  The  vomiting  of  pregnancy  and  dis- 
ordered uterine  function  in  the  female,  and  of  cerebral  and  renal  disease 
in  both  sexes,  is  a  matter  of  common  observation.  In  the  child,  however, 
this  sympathy  is  still  more  frequently  manifested.  Vomiting  is  a  common 
symptom  at  the  beginning  of  most  forms  of  acute  illness  and  in  many 
children  may  be  excited  by  any  casual  distiu'bance.  The  brain  again 
shows  a  marked  sympathy  with  irritation  of  the  more  important  organs. 
Headache,  vertigo,  delirium,  and  stupor  are  phenomena  by  no  means  con- 
fined to  cases  of  intra-craniai  suffering.     Any  serious  inflammatory  disease 


INTRODUCTORY    CHAPTER.  3 

in  the  child  may  be  accompanied  by  such  symptoms  ;  indeed,  the  ex- 
pression of  cerebral  sympathy  may  be  so  decided  as  completely  to  divert 
attention  from  the  part  which  is  really  affected.  The  onset  of  pneumonia 
is  sometimes  complicated  by  such  deceptive  symptoms,  and  the  same  cause 
for  misapprehension  may  be  found  in  cases  of  pericarditis  and  inflammation 
of  the  peritoneum.  So,  also,  the  violent  nocturnal  delirium — the  so-called 
"  night  terrors  "—of  children  v^^ho  suffer  from  worms  or  other  form  of  gas- 
tro-intestinal  derangement  must  be  within  the  experience  of  all. 

One  of  the  best  illustrations  of  the  excitability  of  the  nervous  system 
in  early  childhood  is  seen  in  the  case  of  convulsions.  An  eclamptic  attack 
is  a  symptom  which,  in  the  majority  of  cases,  has  a  far  less  grave  signifi- 
cance in  the  young  child  than  it  has  in  the  adult.  In  the  latter  it  is  usually 
the  evidence  of  some  serious  cerebral  lesion,  and  its  occurrence  excites  the 
greatest  alarm.  In  the  child,  on  the  contrary,  "  a  fit "  is  a  common  ex- 
pression of  disturbance  in  the  nervous  system.  It  may  be  induced  in  some 
children  by  a  trifling  irritant ;  and  in  cases  of  acute  illness  is  often  seen  at 
the  beginning  of  the  attack,  taking  the  place  of  the  rigor  which  is  so 
familiar  a  symptom  at  the  onset  of  the  febrile  disease  in  the  adult.  Con- 
vulsions, however,  are  not  always,  in  the  child,  of  this  innocent  character. 
In  earlier  as  in  later  hfe,  they  may  occur  as  a  consequence  of  cerebral  dis- 
ease ;  but  in  such  a  case  they  are  repeated  frequently,  and  are  succeeded 
by  coma,  rigidity,  paralysis,  and  other  signs  of  centric  irritation.  As  a 
rule,  single  fits,  or  convulsions  unaccompanied  by  other  indication  of 
nerve-lesion,  occurring  in  an  apparently  healthy  child,  are  purely  reflex, 
and  have  no  gravity  whatever. 

Extreme  excitability  of  the  nervous  system  is,  therefore,  in  early  child- 
hood, a  natural  physiological  condition  which  exercises  an  important  influ- 
ence in  disturbing  the  orderly  evolution  of  symptoms.  Into  an  otherwise 
simple  case  it  introduces  a  number  of  redundant  features  which  confuse 
the  observer,  and  may  possibly  divert  his  attention  from  the  actual  seat  of 
suffering.  This  normal  nervous  irritability  is  subject  to  variations.  Thus, 
it  may  be  temporarily  intensified  by  causes  which  23roduce  sudden  depres- 
sion of  strength,  such  as  severe  acute  diarrhoea,  or  rapid  loss  of  blood.  In 
rickets,  again,  a  peculiar  feature  of  the  disease  is  the  extraordinary  excita- 
bility of  the  nervous  system.  As  a  rule,  however,  in  chronic  disease,  when 
the  interference  with  nutrition  is  slow  and  long-continued,  an  exactly  op- 
posite effect  is  produced.  A  young  child,  especially  an  infant,  if  exposed 
for  a  considerable  time  to  injurious  influences  so  as  to  suffer  both  in  flesh 
and  strength,  gradually  loses  his  susceptibility  to  reflex  iri'itation,  and  the 
excitability  of  his  nervous  system  becomes  less  and  less  obvious  until  it 
finally  disaj)pears  almost  entirely.  In  a  child  so  enfeebled,  the  system, 
instead  of  reacting  violently  against  any  intercurrent  irritation,  appears 
almost  insensible  to  nervous  impressions.  If  an  attack  of  acute  iUness 
occui*,  we  look  in  vain  for  the  usual  signs  of  general  disquiet.  Even  the 
ordinary  symptoms  of  local  suffering  may  be  diminished  or  suppressed  ; 
and  were  it  not  for  the  increase  of  weakness,  and  perhaps  for  a  rise  of  tem- 
perature, the  complication  might  be  altogether  overlooked. 

This  obtuseness  of  the  nervous  system  is  only  seen  as  a  consequence  of 
long-continued  and  profound  malnutrition.  In  all  such  cases,  therefore, 
we  shoiild  watch  very  narrowly  for  inflammatory  complications,  remember- 
ing that  such  intercurrent  diseases  may  give  rise  to  but  few  symptoms,  and 
may  easily  escape  notice. 

Another  peculiarity  of  early  life  which  attracts  attention,  is  the  large 
share  taken  in  infantile  disorders  by  mere  disturbance  of  function,  and  the 


4       .  DISEASE   11^   CHILDEEN. 

serious  consequences  which  may  arise  from  derangement  as  distinguished 
from  disease.  Infants  quickly  part  with  their  heat  and  are  easity  chilled. 
They  are,  therefore,  pecuharly  prone  to  catarrhal  disorders,  and  these,  if 
severe,  may  produce  material  interference  with  the  functions  of  the  organ 
affected.  No  doubt  the  excitability  of  the  nervous  system  helps  to  increase 
the  gravity  of  these  derangements.  The  commotion  into  which  the  whole 
system  is  thrown  by  the  attack,  tends  to  exhaust  the  patient  and  greatly  to 
enhance  the  enfeebling  influence  of  the  complaint.  In  infancy,  death  is 
a  not  uncommon  consequence  of  these  disorders ;  and  it  is  for  this  rea- 
son that  2^ost  mortem  examinations  in  the  infant  are  so  often  unsatisfactory. 
It  constantly  happens  that  a  young  child  is  seized  with  alarming  symptoms 
of  iUness  and  quickly  dies,  yet  on  opening  the  body  no  sufficient  morbid 
appearances  are  discovered  to  explain  the  fatal  issue  of  the  case. 

Children  differ  h'om  adults  in  yet  another  respect.  Diathetic  tenden- 
cies are  especially  active  in  early  life.  They  exert  a  remarkable  influence 
upon  the  growing  body,  shaping  the  figure,  moulding  the  features,  and  so 
ordering  the  structure  of  organs  that  any  interference  with  the  nutritive 
processes,  such  as  may  be  produced  by  ordinary  insanitary  agencies,  is 
followed  by  widely  distributed  mischief.  Sir  William  Jenner  has  drawn 
attention  to  the  number  of  organs  affected  at  the  same  time  in  cases  of 
diathetic  disease  in  the  child.  In  a  bad  case  of  inherited  syphihs,  few  tis- 
sues or  organs  escape  ;  in  scrofula  the  lesions  may  be  almost  universal ; 
and  in  acute  tuberculosis  all  the  cavities  of  the  body  may  be  simultane- 
ously affected.  Thus,  according  to  the  constitutional  chai'acter  of  the  pa- 
tient and  the  nature  of  his  ailment,  a  child  may  die  from  mere  arrest  of 
function,  with  tissues  sound,  organs  healthy,  and  no  morbid  appearances 
left  to  declare  the  nature  of  the  complaint ;  or  may  succumb  to  a  profound 
and  general  disease  which  visits  every  part  of  the  body  and  leaves  scarcely 
any  organ  unaffected. 

It  is  sometimes  said  that  in  a  healthy  child  acute  disease  naturally  tends 
to  recovery,  but  this  statement  must  not  be  taken  without  quahfication. 
There  are  some  diseases,  such  as  typhoid  fever,  measles,  and  perhaps 
croupous  pneumonia,  which  commonly  run  a  milder  course  in  earher  than 
they  do  in  later  life  ;  but  there  are  others,  esjoecially  acute  affections  of 
the  gastro-intestinal  tract,  which  weigh  with  pecuhar  severity  upon  the 
young.  In  infancy  the  patient  is  so  dependent  upon  a  fi-equent  suj)ply  of 
nourishment  that  an  abnij)t  interference  with  the  nutritive  processes,  such 
as  occurs  in  some  forms  of  bowel  complaint,  is  an  event  of  the  utmost 
gravity.  Often  it  is  followed  by  so  much  exhaustion  that  the  infant  rap- 
idly sinks  and  dies.  It  is  this  sudden  and  complete  cutting  off  of  the  nu- 
tritive supply  which  constitutes  the  chief  danger  of  acute  disease  in  the 
child  ;  and  in  early  life  illness  is  often  serious  in  exact  proportion  to 
the  degree  in  which  the  alimentary  canal  takes  part  in  the  derangement. 
When  digestion  is  not  arrested  and  the  system  still  continues  to  receive 
nourishment,  the  child,  if  in  favourable  conditions  and  of  healthy  constitu- 
tion, will  probably  recover.  The  recuperative  power  of  nature  is  very 
great,  especially  in  the  young ;  but  that  it  may  be  free  to  operate  it  is  es- 
sential that  no  unfavourable  condition  be  present  to  impede  the  natural 
course  of  the  illness.  Over  and  above  gTave  implication  of  the  digestive 
organs,  other  untoward  elements  may  enter  into  a  case,  and  each  of  these 
has  an  influence  in  weakening  the  natural  tendency  to  mend.  The  age  is 
a  matter  of  great  importance.  A  new-born  infant  has  but  a  feeble  hold 
upon  life  and  quickly  succumbs  to  an  attack  of  acute  illness.  Later,  the 
child  m-ay  be  burdened  with  a  diathetic  taint  which  has  ah-eady  impaired 


INTEODUCTOEY   CHAPTEE.  5 

his  Butrition  and  lowered  his  Adtal  energies.  Moreover,  he  may  be  ham- 
pered by  unhealthy  surroundings  which  intensify  the  weakening  influence 
of  the  original  disease,  and,  indeed,  by  themselves  are  often  powerful 
enough  to  prevent  recovery. 

Therefore  it  is  only  in  children  of  healthy  constitution  who  are  placed 
under  favourable  conditions  that  illness  can  be  said  naturally  to  tend  to  re- 
covery, and  in  them  only  after  the  period  of  earliest  infancy  has  passed  by, 
and  in  cases  where,  nutrition  not  being  completely  arrested,  a  limited  sup- 
ply of  nourishment  continues  to  be  introduced  into  the  system. 

Sudden  death  in  early  childhood,  is  due,  as  a  rule,  to  laryngismus,  to 
syncope,  or  to  collapse  of  the  lung ;  and  occasionally  it  is  seen  as  a  conse- 
quence of  convulsions.  Spasm  of  the  larynx  is  the  common  cause  of  death 
in  children  who  are  apparently  healthy.  Those  who  die  suddenly  in  the 
course  of  an  acute  illness  or  during  convalescence,  do  so  usually  from  syn- 
cope, or  in  rarer  cases  from  thrombosis  in  the  pulmonary  artery.  In 
wasted  infants  sudden  death  is  more  commonly  the  consequence  of  pul- 
monary collapse.  Wlien  a  disease  is  about  to  end  fataUy  the  extremity  of 
the  danger  is  shown  by  a  marked  alteration  in  the  temperature.  In  some 
cases  we  notice  a  rapid  fall,  the  thermometer  registering  only  96°  or  97° 
in  the  rectum.  In  others  there  is  a  sudden  increase  in  the  bodily  heat, 
and  the  temperature  rises  quickly'  to  108°  or  109°.  The  ante-mortem 
cooling  is  usually  noticed  in  chronic  ailments  and  in  bronchitis  with  col- 
lapse of  the  lung.  The  rapid  increase  in  heat  is  common  in  cerebral  affec- 
tions and  in  cases  of  acute  gastro-intestinal  derangements.  Other  un- 
favomrable  signs  are  lividity  of  face,  refusal  of  food,  thrush^  rapidity  and 
feebleness  of  the  pulse,  heaviness  and  stupor. 

In  acute  disease  when  recovery  takes  place,  convalescence  is  usually 
rapid.  In  an  uncomplicated  case  the  strength  appears  to  be  recovered  al- 
most as  quickly  as  it  was  lost.  Directly  the  temperature  falls,  digestion 
and  nutrition  resume  their  course  and  in  a  surprisingly  short  time  the 
child  is  well.  If  convalescence  is  delayed  in  such  a  case  it  is  almost  inva- 
riably the  consequence  of  a  complication,  and  it  must  be  remembered  that 
this  accident  is  far  fi'om  uncommon  in  the  child.  In  all  forms  of  catarrhal 
derangement — a  variety  of  disease  to  which  childhood,  as  has  been  said,  is 
peculiarly  prone — a  gastro-intestinal  compUcation  may  increase  the  gravity 
of  the  illness  and  delay  the  process  of  repair.  Sometimes  the  depurative 
functions  of  the  kidneys  are  imperfectly  performed.  Sometimes  an  unab- 
sorbed  patch  of  consolidation  in  the  lung  interferes  with  the  return  of 
strength.  In  all  cases,  therefore,  where  convalescence  from  acute  disease 
is  delayed,  or  having  began,  appears  to  falter,  we  should  make  careful  ex- 
amination of  the  various  organs  so  as  to  discover  the  mischief  and  apply  a 
remedy.  ' 

In  cases  of  chronic  illness  convalescence  is  usually  tardy.  The  delay, 
no  doubt,  is  partly  owing  to  the  fact  that  this  class  of  disease  is  common 
in  children  of  a  scrofulous  habit  of  body  ;  and  the  strumous  cachexia  is  in 
itself  a  bar  to  rapid  improvement.  It  is,  however,  also  often  due  to  the 
nature  of  the  illness.  In  early  life,  especially  in  infancy,  chronic  ailments 
commonly  affect  the  alimentary  canal,  either  primarily  or  secondarily,  and 
the  progress  of  such  complaints  to  recovery  is  invariably  slow. 

In  the  following  pages  the  term  "  infancy  "  is  confined  to  the  two  first 
years  of  life,  or  to  the  period  which  ends  with  the  completion  of  the  first 
dentition  ;  "  early  childhood  "  to  the  period  between  the  close  of  the  sec- 
ond and  the  close  of  the  fourth  year.  The  period  of  childhood  ends  at 
puberty.     This  important  change  occurs  at  various  ages,  especially  in  girls  ; 


6  DISEASE   IlSr   CHILDREN. 

and  some  young  people  remain  cliildi'en  botli  in  mind  and  body  to  a  much 
later  date  than  others. 

In  the  examination  of  an  infant  or  young  child  every  care  should  be 
taken  to  avoid  abruptness  or  hiu'ry.  We  must  remember  that  we  have  to 
do  with  beings  who  act  not  fi-om  reason,  but  from  instinct ;  that  any  sud- 
den movement  frightens  them,  a  little  pressure  hui'ts  them,  and  in  either 
case  a  cry  and  a  struggle  bring  the  examination  abruptly  to  a  close.  Again, 
young  childi'en,  as  a  rule,  dislike  the  sight  of  a  strange  face,  and  if  old 
enough  to  understand  the  object  of  the  visit,  are  ah'eady  prepared  to  look 
with  distrust  upon  the  "doctor."'  Still,  it  is  a  mistake  to  suppose  that 
children  always  make  unmanageable  patients.  They  are  no  doubt  cj^uick 
to  take  flight ;  but  it  shoiild  be  the  constant  care  of  the  practitioner  to 
avoid  any  look  or  gesture  which  may  arouse  theu*  suspicions.  If  he  look, 
speak,  and  move  gently,  and  do  not  huny,  most  young  children  will  let 
themselves  be  examined  thoroughly  without  great  difficulty. 

On  entering  the  room  it  is  well  to  accustom  them  to  our  presence  be- 
fore we  even  appear  to  notice  them  at  all.  This  interval  can  be  usefully 
occupied  by  questioning  the  mother  as  to  the  onset  of  the  illness,  and  the 
character  of  the  early  symptoms.  We  can  also  take  this  oppoi'tunity  of 
inspecting  the  motions  or  vomited  matters.  In  searching  into  the  histoiy 
of  the  case  it  is  especially  desirable  to  obtain  some  starting-point  for  our 
investigations.  The  question  "When  did  the  indisposition  begin?"  often 
receives  only  a  vague  reply  ;  while  an  inquiiy  as  to  the  time  which  has 
elaj)sed  since  the  child  was  last  in  good  health  may  ehcit  an  account  of 
more  or  less  interference  with  nutrition  and  indefinite  malaise  extending 
over  a  considerable  interval.  Some  tact  is  often  required  in  obtaining  a 
definite  account  of  the  beginning  and  early  progress  of  the  illness.  It  is 
important  to  avoid  suggesting  a  rejDly  by  the  character  of  the  question, 
while  it  is  often  necessary  to  be  minute  in  oiu-  inquuies  in  order  to  stimu- 
late a  flagging  memory. 

In  infants  and  young  children  much  may  be  learned  from  mere  inspec- 
tion of  the  face.  It  is  an  advantage  in  these  cases  to  find  the  patient 
asleep.  We  can  then  study  at  leisiu-e  the  colour-  and  general  expression  of 
the  face,  the  form  of  the  features,  the  presence  or  absence  of  lines  or 
wiinkles,  and  remark  if  the  nares  act  in  respiration  or  the  eyehds  close 
incompletely.  We  can  besides  notice  the  attitude  of  the  child,  can  count 
the  pulse  and  resj)iration,  and  can  observe  their  degree  of  reg"ulaiity  or 
any  deviation  from  the  healthy  state.  Even  if  the  child  be  awake,  many 
of  these  points  can  be  noticed  if  we  approach  quietly  and  do  not  speak  to 
or  offer  to  touch  the  patient.  Any  movements  he  may  make  at  this  time 
in  his  cot  must  receive  due  attention,  for  they  often  convey  very  valuable 
information. 

These  points  having  been  noticed,  the  temperature  should  be  taken. 
In  doing  this,  if  the  patient  be  an  infant,  it  is  desirable  to  introduce  the 
bulb  of  the  thermometer  into  the  rectum,  for  at  this  early  age  the  differ- 
ence between  the  internal  and  external  temperature  of  the  body  is  often 
considerable.  The  child  should  next  be  completely  stripped  of  his  clothes. 
The  state  of  his  skin  can  then  be  ascertained,  noting  the  presence  or 
absence  of  eruption  ;  and  a  careful  examination  must  be  made  of  the 
abdomen  and  chest.  If  the  child  lose  his  temper  at  this  time,  the  Cjuahty 
and  strength  of  his  ciy  should  be  remarked.  At  the  end  of  the  visit  the 
gums,  mouth,  and  throat  should  be  inspected,  and  if  any  of  the  child's 
water  can  be  procui'ed,  it  should  be  examined  for  albumen,  and  its  density 
and  degree  of  aciditj-  ascertained. 


IlSrTEODITCTOEY    CHAPTEE.  7 

After  this  rapid  sketch  of  the  method  upon  which  the  clinical  examina- 
tion of  the  infant  and  young  child  should  be  conducted,  the  chief  points  to 
which  attention  must  be  directed  may  be  considered  more  in  detail. 

In  the  new-born  infant  the  tint  of  the  face  immediately  after  birth  is 
a  dull  red.  The  redness,  however,  soon  begins  to  subside  ;  in  a  day  or 
two  the  complexion  assumes  a  slight  yellow  tint,  and  then  passes  into  its 
normal  coloring.  The  yellow  tint  and  its  diagnosis  from  infantile  jaundice 
are  referred  to  elsewhere  (see  Jaundice). 

The  clear  fresh  complexion  of  a  healthy  baby  or  young  child  is  familiar 
to  every  one.  A  loss  of  its  purity  and  clearness  is  one  of  the  first  indica- 
tions of  digestive  derangement.  The  face  becomes  muddy-looking  and  the 
upper  lip  whitish  or  bluish.  Blueness  of  the  upper  lip  in  early  life  is 
a  common  sign  of  laboured  digestion.  In  some  children  difi&cult  digestion 
is  shown  by  an  earthy  tint  of  the  face  which  spreads  to  the  forehead.  It 
appears  a  short  time  after  the  meal  and  may  last  several  hours.  In  chronic 
bowel  complaints  the  earthy  tint  is  constant.  It  is  common  in  cases  of 
chronic  diarrhoea  in  the  infant,  and  if  at  the  same  time  there  is  much 
emaciation,  the  derangement  is  likely  to  prove  obstinate.  In  syphilis  the 
prominent  parts  of  the  face — the  nose,  cheeks,  chin,  and  forehead — assume 
a  swarthy  hue.  In  lardaceous  disease  the  complexion  is  peculiarly  pallid 
and  bloodless  ;  in  rickety  children  whose  spleens  are  greatly  enlarged  it 
has  a  greenish  or  faint  olive  cast ;  and  in  cyanosis  the  face  has  a  char- 
acteristic leaden  tint,  the  conjunctivae  are  congested,  and  the  eyelids  and 
lips  thick  and  purple.  Livid ity  of  the  skin  round  the  mouth  and  nose 
with  a  purple  tint  of  the  eyelids  is  common  as  a  result  of  deficient  aeration 
of  the  blood.  In  severe  cases  the  cheeks  at  the  same  time  have  a  dull 
white  color,  and  the  symptom  is  an  unfavourable  one.  In  the  spasmodic 
stage  of  whooping-cough  the  face  looks  swollen  as  well  as  livid,  the  lips 
and  eyelids  are  purple  and  thick,  and  the  conjunctivae  are  congested  and 
often  bloodshot. 

In  addition  to  the  actual  tint  of  the  face  the  general  expression  must 
receive  attention.  In  a  healthy  babe  the  physiognomy  denotes  merely 
sleepy  content,  and  no  lines  mark  the  smooth  uniform  surface.  Pain  is 
indicated  by  a  contraction  of  the  brows  which  wrinkles  the  skin  of  the  fore- 
head. This  is  especially  noticeable  if  the  head  is  the  seat  of  suffering.  If 
the  pain  be  in  the  abdomen  the  nose  often  looks  sharp,  the  nostrils  are 
dilated,  and  the  child  draws  up  the  corners  of  the  mouth  with  a  peculiar 
expression  of  distress.  In  every  case  of  serious  disease  the  face,  even  in 
repose,  has  a  haggard  look,  which  must  not  be  disregarded.  If  this  be  ac- 
companied by  a  hoUowness  of  the  cheeks  and  eyes  the  result  is  a  ghastly 
expression  which  cannot  escape  attention  ;  but  a  distressed  look  may  be 
seen  in  the  face  although  there  is  no  loss  of  roundness  of  feature.  If  this 
be  the  case,  even  in  the  absence  of  striking  symptoms,  we  may  confidently 
predict  the  onset  of  serious  disease. 

Often  an  inspection  of  the  face  will  help  us  to  a  knowledge  of  the  part 
of  the  body  affected.  Many  years  ago  M.  Jadelot  pointed  out  certain  lines 
or  furrows  in  the  face  of  an  ailing  infant  which  by  their  position  indicate 
the  seat  of  the  derangement,  thus  : 

The  occulo-zygomatic  line  begins  at  the  inner  canthus  of  the  eye,  passes 
thence  downwards  and  outwards  beneath  the  lower  lid  and  is  lost  on  the 
cheek  a  little  below  the  projection  of  the  malar  bone.  This  line  points  to 
disease  or  derangement  of  the  brain  and  nervous  system. 

The  naml  line  rises  at  the  upper  part  of  the  ala  of  the  nose  and  passes 
downwards  curline;  round  the  corner  of  the  mouth.    Tliis  line  is  a  constant 


8  DISEASE  IN   CHILDREN. 

feature  of  abdominal  miscliief,  and  is  never  absent  in  cases  of  gastro- 
intestinal derangement. 

The  labial  line  begins  at  tbe  angle  of  the  mouth  and  runs  outwards  to  be 
lost  in  the  lower  jDart  of  the  face.  This  is  more  shallow  than  the  preced- 
ing. It  is  a  fairly  trustworthy  sign  of  disease  in  the  lungs  and  air- 
passages. 

These  lines  have  a  distinct  practical  value  and  should  be  always  attended 
to.  We  should  also  notice  if  the  eyelids  close  completely,  for  imperfect 
closure  of  the  lids  during  sleep  is  a  common  sign  of  weakness.  MoreoA^er, 
it  must  not  be  forgotten  to  ascertain  the  condition  of  the  pupils  and  the 
presence  or  absence  of  squint.  The  value  of  these  symptoms,  and  of 
others  connected  with  the  eye,  is  referred  to  elsewhere  (see  page  261).  The 
nares  must  not  be  forgotten.  If  they  act  in  respiration  the  movement  is  a 
common  accompaniment  of  laboured  breathing  and  often  indicates  an 
impediment  to  the  respiratory  function.  It  may,  however,  be  present  in 
cases  where  there  is  no  conscious  dyspnoea,  and  is  sometimes  seen  in  sim- 
ple pyrexia.  Even  the  shape  of  the  features  must  be  attended  to.  An 
elongated  head  with  square  forehead  and  small  lower  jaw  are  characteristic 
of  rickets  ;  a  broad  flat  bridge  to  the  nose,  especially  if  conjoined  with 
prominence  of  the  forehead  and  absence  of  eyebrows,  suggests  syphihs ; 
and  a  big  globular  head  surmounting  a  small  face  and  little  pointed  chin 
indicates  immistakably  chronic  hydrocephalus. 

The  attitude  of  the  child  as  he  lies  in  his  cot  is  not  to  be  overlooked. 
Sometimes  it  is  characteristic.  A  healthy  infant  or  young  child,  even  if 
hdng  on  his  back,  inclines  to  one  side  and  turns  his  head  so  as  to  bring 
the  "cheek  in  contact  with  the  pillow.  If  a  baby  be  found  lying  motionless 
on  his  back,  with  closed  eyes  and  face  directed  straight  upwards  to  the 
ceiling  above  him,  he  is  probably  the  subject  of  serious  disease.  This  po- 
sition may  be  seen  when  the  child  is  imconscious,  as  from  tubercular 
meningitis  ;  or  is  profoundly  depressed,  as  in  acute  inflammatory  diar- 
rhoea. If  the  child  he  on  his  side  with  his  head  greatly  retracted  on  his 
shoulders,  it  is  a  suspicious  sign  of  intra-cranial  disease.  If  in  such  a  po- 
sition the  breathing  is  audible  and  hoarse,  the  case  is  probably  one  of 
laryngitis,  or  there  is  some  impediment  to  the  passage  of  air  through  the 
glottis.  If  the  patient  be  found  in  his  cot  resting  on  his  elbows  and  knees 
with  his  forehead  buried  in  the  pillow,  or  if  he  sleep  lying  on  his  belly, 
there  is  no  doubt  abdominal  discomfort.  These  positions  are  common 
with  rickety  children.  If  the  child  press  his  eyelids  against  the  pillow, 
tm-ning  partially  on  his  chest,  we  may  suspect  intolerance  of  light. 

Healthy  infants  and  childi-en  sleep  perfectly  quietly.  Frequent  turn- 
ing of  the  body  or  twitching  of  the  muscles  generally  indicates  feverishness 
or  digestive  derangement.  If  the  child  move  his  head  constantly  from 
side  to  side  on  the  piUow,  he  is  probably  annoyed  with  pain  in  the  head 
or  ear.  Frequent  carrying  of  the  hand  to  the  forehead  or  side  of  the  head 
has  usually  the  same  significance.  If  the  child  repeatedly  flex  the  thighs 
on  the  abdomen,  and  cry  violently  in  sudden  paroxysms,  he  is  probably 
suffering  from  cohc. 

The  cry  of  the  child  is  a  symptom  of  considerable  importance.  It  is 
usually  ehcited  by  hunger  or  "uneasiness,  and  from  the  manner  of  crying 
we  can  often  gather  considerable  information.  A  Imngry  infant  in  most 
cases  clenches  his  hands  and  flexes  his  hmbs — both  arms  and  legs — as  he 
utters  his  complaints  ;  and  Mall  often  continue  to  do  so  until  his  desires 
are  satisfied.  Thirst  may  also  be  a  cause  of  crying,  and  may  be  suspected 
if  the  child  sucks  his  lips  repeatedly,  has  a  dry  mouth,  or  has  been  suffer^ 


INTRODUCTOEY    CHAPTER.  9 

ing  from  purging.  If  lie  be  tortured  by  colicky  pain,  the  cry  is  violent 
and  paroxysmal,  and  is  accompanied  by  uneasy  movements  of  the  body 
and  jerking  of  the  lower  limbs.  The  belly  is  also  full  and  hard,  and  there 
is  often  a  blue  tint  round  the  mouth.  A  shrill  scream  uttered  at  intervals, 
the  child  lying  in  a  drowsy  state  with  closed  eyes,  is  suggestive  of  tuber- 
cular meningitis.  A  constant  unappeasable  screaming  is  often  the  conse- 
quence of  ear-ache.  This  painful  affection  is  very  common  in  infants,  and 
should  be  always  suspected  if  the  lamentations  continue  without  intermis- 
sion, and  the  child  frequently  presses  the  side  of  his  head  against  his 
mother's  breast.  The  pain  of  pleurisy  will  also  cause  violent  crying.  In 
this  case  pressure  upon  the  sides  of  the  chest,  as  in  lifting  the  child  up, 
causes  an  evident  increase  in  his  suffering.  Any  alteration  in  the  cjuality 
of  the  cry  must  be  noted.  It  may  be  hoarse  in  a  young  infant  from  in- 
herited syphilis  ;  in  an  older  child  from  laryngitis  or  enlargement  of  the 
bronchial  glands. 

In  a  healthy  infant  a  cry  is  excited  at  once  by  anything  which  causes 
him  discomfort  or  inconvenience  ;  therefore  the  absence  of  crtjing  is  a 
symj^tom  which  should  always  receive  due  attention,  as  it  may  betoken  se- 
rious disease.  In  inflammatory  affections  of  the  lungs,  in  pulmonary  col- 
lapse, and  in  advanced  rickets  where  the  bones  are  softened,  a  child  will 
bear  considerable  discomfort  without  loud  complaint,  for  he  has  a  press- 
ing want  for  air  and  dare  not  hold  his  breath  to  cry.  So,  also,  in  severe 
diarrhoea  or  any  other  illness  which  causes  great  reduction  of  strength,  the 
child,  on  account  of  his  weakness,  cries  little  if  at  all.  In  cases  of  pro- 
found weakness  he  will  often  be  noticed  to  draw  up  the  corners  of  his 
mouth  and  wrinkle  his  brows  as  if  to  cry  without  making  any  sound. 

In  the  act  of  crying  tears  are  copiously  secreted  after  the  age  of  three 
or  four  months.  In  serious  disease,  however,  the  lachrymal  secretion 
often  fails.  Therefore  the  absence  of  tears  must  be  taken  to  indicate  con- 
siderable danger. 

The  pulse  in  the  infant  can  seldom  be  counted,  except  during  sleep  ; 
and  even  if  its  rapidity  can  be  ascertained  the  information  thus  derived  is 
of  little  value.  The  rapidity  of  the  pulse  in  infancy  is  constantly  varying. 
The  least  movement  excites  the  heart's  action,  and  mental  emotions,  such 
as  frigvht  or  anger,  almost  double  the  rapidity  of  the  cardiac  contractions  ; 
so  that,  according  as  to  whether  the  infant  is  awake  or  asleep,  is  perfectly 
quiet  or  has  just  moved,  the  pulse  may  vary  from  between  80  and  90  to 
160  or  180.  As  a  test  of  physical  vigour  in  babies  the  pulse  is  worthless. 
In  this  respect  the  fontanelle  is  of  far  greater  value.  In  infants  under 
twelve  months  old  a  sinking  of  the  fontanelle  is  a  sure  sign  of  reduction  of 
the  strength  ;  and  in  touching  a  child  of  this  age  our  first  care  should  be  to 
pass  the  finger  over  the  top  of  the  head  and  ascertain  the  condition  of  this 
part  of  the  skull.  In  wasted  babies  the  fontanelle  often  forms  a  cup- 
shaped  depression  ;  and  if  the  loss  of  flesh  is  very  rapid,  as  when  a  pro- 
fuse drain  occurs  from  the  bowels,  the  cranial  bones  may  often  be  felt  to 
overlap  slightly  at  the  sutures.  Excess  of  fluid  in  the  skull-cavity  or  a  hy- 
pereemic  state  of  the  brain  causes  bulging  and  tenseness  of  the  fontanelle. 
Unless  very  distended  the  membrane  is  not  motionless.  It  can  be  seen  to 
move  with  respiration  and  to  sink  appreciably  as  air  is  drawn  into  the 
lungs. 

After  the  period  of  infancy  has  passed,  the  pulse  becomes  a  far  more 
trustworthy  guide.  'During  sleep  it  is  fifteen  or  twenty  beats  slower  than 
during  the  waking  state,  and  may  then  be  occasionally  irregular  in  rhythm 
or  even  completely  remittent.     When  the  child  wakes  the  pulsations  in- 


10  DISEASE   IX   CHILDREN. 

crease  in  frequency  and  usually  rise  above  100.  If  at  this  age  tiie  pulse  is 
found  to  fall  as  low  as  60  or  70  in  a  cliild  wlio  is  not  asleep,  and  to  intermit 
completely,  the  sign  may  be  significant  of  tubercular  meningitis.  This 
matter  is  elsewhere  referred  to  (see  page  359). 

The  respirations  should  be  always  counted.  In  new-born  infants  their 
number  is  about  40  or  perhaps  more  in  the  minute.  But  the  breathing 
soon  becomes  less  rapid,  although  for  a  long  time  the  movements  are  more 
frequent  than  in  the  adult,  and  even  after  the  second  year  are  usually  over 
20  in  the  minute.  The  normal  average  is  difficult  to  ascertain,  for  like 
the  pulsations  of  the  heart  the  breathing  varies  greatly  in  rapiditj'.  It  is 
rather  slower  duiing  sleep  than  when  the  child  is  awake,  but  is  apt  to  be- 
come more  hurried  fi'om  shght  causes.  More  important  than  the  actual 
rapidit}^  of  either  the  breathing  or  the  pulse  is  the  ratio  the  two  bear  to 
one  another.  If  the  breathing  become  rapid  out  of  proportion  to  the 
pulse,  the  discrepancy  should  be  carefully  noted.  The  normal  ratio  is  1 
to  3,  or  3.5.  If  this  proportion  becomes  greatly  per\-erted  and  we  find  one 
respiratory  movement  to  every  two  beats  of  the  pulse,  we  should  suspect 
the  presence  of  pneumonia  or  of  pulmonary  collapse.  The  regularity  of 
the  respiration  is  also  to  be  noticed.  A  slight  iiTegularity,  especially  in 
force,  is  common  in  infants ;  but  if  the  breathing  become  markedly  irreg- 
vlar,  the  sj^mptom  may  be  an  important  one.  Frequent  heavy  sighs  and 
long  pauses,  during  which  the  chest  is  perfectly  motionless,  are  veiy  suspi- 
cious of  tubercular'  meningitis. 

The  temperature  of  the  child  ought  always  to  be  ascertained.  It  must 
be  taken  's^ith  care.  In  a  healthy  infant  the  temperatui'e  of  the  rectum  is 
about  99 "^j  and  is  fairly  constant  throughout  the  day.  It  rises  half  a  degree 
or  so  towards  the  end  of  digestion,  but  a  marked  difference  between  the 
morning  and  evening  temperatui'e  is  not  noticed  in  a  healthy  baby  who 
receives  proper  attention.  According  to  Dr.  Squu'e,  if  the  bodily  heat  is 
found  to  vary  considerably  at  different  times  in  the  day,  the  symptom 
should  suggest  neglect  on  the  part  of  the  nurse  or  dehcacy  of  constitution 
on  the  part  of  the  child.  If  the  infant  be  kept  too  long  without  food  the 
temperature  falls,  and  will  then  rise  again  considerably  after  the  meal.  It 
also  appears  fi'om  Dr.  Squu'e's  interesting  observations  upon  young  babies, 
that  the  temperatui'e  is  rather  lower  during  sleep  than  when  the  child  is 
awake.  Even  after  the  age  of  infancy  the  temperatui'e  is  subject  to  fi-e- 
quent  variations  from  slight  causes  ;  and  in  young  childi'en  mental  emotion 
will  often  induce  a  degTce  of  fever  which  may  be  a  source  of  jDerplexity. 
In  children's  hospitals  it  is  a  common  observation  that  the  bodily  heat  on 
the  evening  of  admission  is  high  even  Avhen  the  disease  is  not  one  usually 
attended  with  fever. 

On  account  of  the  excitability  of  the  nervous  system  in  early  life— -a 
loeculiarity  of  childhood  which  has  been  before  referred  to— children  are 
very  subject  to  what  has  been  called  "  irritative  fever,"  i.e.,  to  a  form  of 
pyrexia  Avhich  results  from  fretting  of  the  system  by  various  sources  of  ii'- 
ritation.  Dentition,  as  is  exj)lained  elsewhere,  is  a  frequent  promoter  of 
this  form  of  febrile  excitement,  and  a  pyrexia  induced  by  this  means  is  apt 
to  comphcate  derangements  ordinarih-  non-febrile  and  be  a  cause  of  con- 
fusion. So,  also,  u'ritation  of  the  bowels  by  scybala,  indigestible  food,  or 
parasitic  worms,  is  a  common  cause  of  elevation  of  temperatui'e  in  the 
young.  The  febrile  movement  resulting  from  the  presence  of  a  local  irri- 
tant, like  other  forms  of  pyrexia  in  childhood,  is  generally  remittent  ;  but 
the  remissions  are  not  always  found  at  the  same  period  of  the  twenty-four 
hours.    There  is  not  always  a  fall  of  temperatui'e  in  the  morning  and  a  rise 


INTEODUCTOEY   CHAPTER.  11 

at  night.  One  of  the  jpeculiarities  of  this  form  of  febrile  disturbance  is 
the  irregularity  of  the  fever.  In  a  young  child  a  temperature  higher  in  the 
morning  than  at  night  should  alwaj's  suggest  some  reflex  cause  for  the 
pyrexia. 

It  is  very  important  not  to  neglect  the  use  of  the  thermometer  in  judg- 
ing of  the  heat  of  the  body,  for  not  only  is  the  hand  very  decei^tive  as  a 
guide,  but  the  skin  of  the  patient  may  appear  to  be  cool  although  the  in- 
ternal temperature  is  several  degrees  above  the  normal  level.  It  is  not 
uncommon  in  cases  of  inflammatory  diarrhoea  to  find  the  extremities  so 
cold  as  to  require  the  application  of  a  hot  bottle,  v^hile  a  thermometer 
placed  in  the  rectum  registers  104°  or  105°.  Sometimes  in  young  children 
the  pyrexia  will  reach  a  very  high  level.  At  the  end  of  an  attack  of  tuber- 
cular meningitis  the  temperature  is  often  109°  or  110°  ;  and  the  same  de- 
gTee  of  febrile  heat  is  occasionally  seen  in  cases  of  acute  gastro-intestinal 
inflammation.  In  either  case  the  symptom  betokens  extreme  danger  ; 
although  it  must  not  be  concluded  that  the  illness  will  inevitably  prove 
fatal.  I  have  known  a  baby  of  a  fe(Nv  weeks  old  recover  after  its  rectal  tem- 
perature had  risen  to  the  alarming  height  of  109°. 

Sometimes  instead  of  an  elevation  the  thermometer  may  show  a  lower- 
ing of  temperatui'e.  In  infants  any  reduction  in  the  bodily  heat  is  usually 
a  sign  of  deficient  nourishment.  In  a  baby  exhausted  by  chronic  vomit- 
ing or  purging  the  temperature  in  the  rectum  may  be  no  higher  than  97°. 
This  is  of  course  an  extreme  case  ;  but  a  lesser  depression  is  often  found 
in  infants  insufficiently  nourished,  either  from  watery  breast-milk  or  an 
linsuitable  dietary.  Again,  in  convalescence  from  acute  disease  the  tem- 
perature usually  remains  for  some  days  or  even  weeks  at  a  lower  level  than 
that  of  health.  This  phenomenon  may  be  often  noticed  after  typhoid  and 
the  other  eruptive  fevers. 

Before  leaving  the  subject  of  temperature,  reference  may  be  made  to 
the  pyrexia  which  sometimes  attends  rapid  gTOwth.  Several  cases  have 
come  under  my  notice  in  which  growing  gii'ls  were  exciting  great  anxiety 
by  a  persistent  evening  temperature  of  over  100°.  In  one  such  case,  a  girl 
of  twelve  had  been  kept  in  bed  for  five  weeks  and  treated  for  typhoid 
fever,  the  girl  all  the  time  begging  to  get  vip  and  declaring  herself  to  be 
perfectly  well.  The  patient  was  brought  to  me  from  the  country  for  an 
opinion,  as  the  temperature  for  six  weeks  had  varied  every  night  between 
99°  and  100.6°.  I  examined  the  child  carefuUy  and  could  find  nowhere  any 
sign  of  disease.  She  looked  healthy  and  was  said  to  be  growing  rapidly. 
I  accordingly  advised  that  she  should  be  no  longer  treated  as  an  invalid, 
but  should  be  allowed  to  get  up,  be  put  upon  ordinary  diet,  and  be  sent 
as  much  as  possible  into  the  open  air.  This  was  done,  and  at  the  end  of 
a  fortnight  the  temperatui-e  became  normal  and  did  not  afterwards  rise. 

Having  obtained  all  the  information  we  can  without  unnecessarily  dis- 
turbing the  patient,  we  should  next,  in  the  case  of  an  infant  or  young  child, 
have  the  clothes  completely  removed  so  as  to  be  able  to  make  a  thorough 
examination  of  the  surface  of  the  body.  We  can  thus  notice  the  condition 
of  the  skin  as  to  texture  and  elasticity,  and  remark  the  presence  or  ab- 
sence of  eruptions  or  signs  of  inflammatory  swelling.  In  a  healthy  young 
child,  the  skin  is  delicate  and  soft,  and  of  a  beautiful  pinkish- white  tint.  If  it 
feel  dry  and  have  an  earthy  hue,  the  change  is  suspicious  of  chronic  bowel 
complaint.  If  the  skin  is  wanting  in  elasticity,  we  should  susj)ect  tubercu- 
losis or  renal  disease  ;  and  if  the  kidneys  be  performing  their  functions 
imperfectly,  the  skin  may  be  often  seen  to  lie  in  wrinkled  folds  ujDon  the 
abdomen.     Dryness,  with  a  dingy  hue  of  the  skin,  is  also  common  in  some 


12  DISEASE  IN   CHILDKElSr. 

forms  of  hepatic  disease,  and  occasionally  in  chronic  tubercular  peritonitis. 
At  this  part  of  the  examination,  any  sign  of  tenderness  either  general  or 
local  should  receive  attention.  The  sharjDer  cry  of  pain  is  usually  to  be 
readily  distinguished  from  the  cry  of  irritability  or  anger.  In  rickets 
there  is  general  tenderness  which  makes  all  pressure  painful.  In  pleurisy 
pressure  upon  the  sides  of  the  chest,  as  in  lifting  the  child  ujy,  is  a  cause 
of  acute  suiSering.  Sometimes  signs  of  local  tenderness  can  be  discovered, 
such  as  may  accompany  the  formation  of  matter  beneath  the  surface  ;  or 
again,  slight  tenderness  of  a  joint  may  be  the  only  indication  of  rheuma- 
tism in  the  child. 

The  attention  should  next  be  directed  to  the  respiratory  movements. 
In  healthy  young  children  respu-ation  is  chiefly  diaphragmatic.  Forcible 
movement  of  the  thoracic  vs^aUs  is  a  sign  of  laboured  breathing,  and  is  a 
constant  symptom  of  broncho-jineumonia.  Great  recession  of  the  lower 
parts  of  the  chest  suggests  an  impediment  to  the  entrance  of  air  into  the 
lungs.  If  at  eaclx  inspiration  there  is  great  recession  of  the  epigastrium, 
the  lower  part  of  the  sternum  being  forced  inwards  so  as  to  produce  a 
deep  hollow  in  the  centre  of  the  body,  the  obstruction  is  probably  in  the 
throat  or  larynx.  Such  a  dei^ression  is  seen  in  the  case  of  retro-pharyn- 
geal  abscess,  in  stridulous  laryngitis,  and  diphtheritic  croup.  If  the  chest 
fall  in  laterally  so  as  to  produce  a  deep  groove,  running  downwards  and 
outwards  at  each  side  of  the  chest,  while  at  the  same  time  a  horizontal  fur- 
row form  at  the  junction  of  the  chest  with  the  abdomen,  the  impediment 
is  due  to  softening  of  the  ribs.  This  is  characteristic  of  rickets. 
Sometimes  in  children  who  suffer  from  enlarged  tonsils  a  cup-shaped  de- 
pression is  seen  at  the  lower  part  of  the  sternum.  It  is  right,  however,  to 
say  that  this  deformity  is  not  confined  to  children  with  enlarged  tonsils. 
I  have  seen  it  well  marked  in  patients  in  whom  the  pharynx  was  perfectly 
normal,  and  in  whom  no  impediment  appeared  to  exist  to  the  entrance  of 
air  into  the  lungs.  If  the  chest  move  more  freely  on  one  side  than  on  the 
other,  we  should  suspect  grave  mischief  on  the  side  on  which  the  move- 
ment is  hampered.  Still,  in  the  child  serious  disease  of  the  chest  may  be 
present  without  our  being  able  to  detect  any  such  difference.  Even  in 
cases  of  copio^is  pleuritic  effusion,  no  impairment  of  movement  in  the  in- 
tercostal spaces  of  the  affected  side  may  be  visible.  Marked  contraction 
of  one  side  of  the  thorax  with  curving  of  the  spine  is  suggestive  of  a  late 
stage  of  pleurisy,  or  of  an  indurated  lung. 

In  the  health}^  child  the  abdomen  moves  freely  in  respu'ation.  If  it  be 
motionless,  therefore,  an  inflammatory  lesion  of  the  belly  should  be  sus- 
pected. If  the  superficial  veins  of  the  abdomen  are  unnaturally  visible, 
the  symjDtom  is  suggestive  of  some  impediment  of  the  abdominal  circula- 
tion, such  as  would  be  produced  by  enlarged  mesenteric  glands  or  hepatic 
■disease.  In  young  children  the  belly  is  always  disproportionately  large. 
Its  size  is  due  to  shallowness  of  the  pelvis,  to  flatness  of  the  diaphragm,  and 
to  laxness  of  the  muscular  walls,  which  yield  before  the  pressure  of  the 
flatus  in  the  bowels.  In  some  healthy  infants  the  abdomen  is  much  larger 
than  it  is  in  others.  The  difference  is  probably  due  in  most  cases  to  an 
exaggerated  amount  of  flatus  formed  in  the  bowels  during  digestion.  The 
size  of  the  belly  from  this  cause  sometimes  alarms  parents  ;  and  it  is  not 
uncommon  to  be  consulted  with  regard  to  this  point  in  the  case  of  young 
children  who  are  in  every  resj)ect  perfectly  healthy.  Often,  however,  the 
enlargement  is  due  to  increase  in  size  of  the  liver  and  spleen,  to  the  pres- 
ence of  a  growth,  or  to  accumulation  of  fluid  in  the  peritoneum.  The  size 
of  the  liver  and  spleen  may  be  ascertained  by  placing  the  hand  flat  upon 


INTEODUCTORY   CHAPTER.  13 

the  abdomen,  the  fingers  pointing  to  the  chest,  and  pressing  gently  with 
the  finger  tips.  In  this  way  with  a  little  practice  the  edges  of  these  organs 
can  readily  be  felt.  At  the  same  time,  if  the  child  be  not  crying,  we  can 
ascertain  the  degree  of  tension  of  the  abdominal  wall  and  the  presence  or 
absence  of  fluctuation.  Abnormal  tension  of  the  parietes,  especially  if  it 
be  more  marked  on  one  side  than  on  the  other,  is  suggestive  of  peritonitis 
or  ulceration  of  the  bowels.  For  the  means  of  diagnosis  of  the  several 
conditions  which  give  rise  to  abdominal  enlargement  the  reader  is  referred 
to  the  chapters  treating  of  these  subjects. 

If,  instead  of  being  distended,  the  belly  is  markedly  retracted  we  have 
reason  to  suspect  the  presence  of  tubercular  meningitis.  To  examine  the 
abdominal  organs  at  all  satisfactorily  the  child  must  lie  on  his  back  with 
his  head  and  shoulders  raised  by  a  pillow.  The  mother  or  nurse  should 
sit  upon  the  bed  by  his  side,  and  the  practitioner  should  take  care  that  the 
hand  he  applies  to  the  belly  is  warm  and  does  not  press  too  abruptly  so  as 
to  give  pain.  This  part  of  the  examination  is  usually  submitted  to  without 
opposition  if  the  child  be  humoured  and  cheerfully  talked  to. 

Even  an  examination  of  the  chest  can  generally  be  undertaken  without 
fear  of  failure.  Infants,  as  a  rule,  seldom  give  much  trouble  ;  and  if  there 
is  any  serious  disease  present  in  the  lung,  they  are  too  much  occupied  by 
the  needs  of  respiration  to  spare  time  to  cry.  In  early  childhood  there  is 
more  reason  to  fear  opposition,  but  with  patience  the  examination  can  usu- 
ally be  carried  to  a  successful  issue.  A  stethoscope  is  seldom  objected  to 
if  it  be  first  placed  in  the  child's  hand  and  called  a  trumpet.  For  further 
remarks  upon  this  subject  and  the  peculiarities  of  the  physical  signs  in 
childhood  the  reader  is  referred  to  the  special  chapter  on  examination  of 
the  chest  in  children. 

Inspection  of  the  mouth  and  throat  should  be  always  deferred  to  the 
end  of  the  visit,  as  this  part  of  the  examination  invariably  produces  every 
manifestation  of  displeasure.  An  infant  will  often  protrude  his  tongue 
when  gentle  pressure  is  made  upon  his  chin,  and  a  finger  can  be  usually 
passed  over  his  gums  without  sign  of  opposition  ;  but  to  look  at  the  throat 
we  are  forced  to  depress  the  tongue.  If  any  symptoms  are  noticed  requir- 
ing the  operation,  every  precaution  should  be  taken  to  render  it  successful. 
The  nurse  sitting  in  a  low  chair  facing  the  window  or  a  good  lamp,  holds 
the  child  straight  upon  her  lap  with  his  back  resting  against  her  chest. 
She  then  with  her  arm  thrown  round  his  body  prevents  the  patient  from 
changing  his  position  or  raising  his  hands  to  his  mouth.  At  the  same  time 
an  attendant  standing  behind  her  with  a  hand  on  each  side  of  the  child's 
face  holds  his  head  in  a  convenient  position.  Matters  being  thus  arranged 
it  is  the  practitioner's  own  fault  if  he  do  not  obtain  a  good  view  of  the 
fauces.  Firmness  is  absolutely  necessary  at  this  point.  Any  other  plan  is 
equally  anno^dng  to  the  patient,  and  is  almost  certain  to  end  in  failure. 
Before  inspecting  the  throat,  the  sides  of  the  neck  should  be  examined  for 
evidence  of  swollen  cervical  glands. 

In  some  cases  it  is  important  to  ascertain  if  the  child  takes  the  breast, 
sucks  the  bottle,  or  drinks  from  a  cup  with  ease.  In  infantile  tetanus  the 
mere  fact  that  the  patient  is  able  to  swallow  enables  us  to  speak  less  un- 
favourably of  his  chances  of  recovery.  In  cases,  too,  of  apparent  stupor,  if 
the  child  still  continue  to  take  his  food  the  sign  is  a  favourable  one.  If  a 
child  be  suffering  from  acute  lung  disease,  he  sucks  by  short  snatches, 
stopping  at  frequent  intervals  to  draw  his  breath.  A  syphilitic  child  with 
occlusion  of  the  nares  sucks  with  great  difficult}',  as  his  nose  is  useless  for 
respiratory  purposes  and  all  air  has  to  pass  through  his  mouth.    An  infant 


14  DISEASE    IX    CIIILDEEX. 

with  laad  thrush  has  much  pain  in  drawing  the  milk  from  soreness  of  his 
mouth  and  tongue,  and  may  refuse  his  bottle  altogether.  If  the  throat  be 
sore  the  child  swallows  noisily,  and  often  rehnquishes  the  nijiple  to  cough. 

Lastly,  the  practitioner  should  be  careful  to  inspect  the  vomited  mat- 
ters and  discharges  from  the  bowels,  as  the  description  of  their  apj)ear- 
ance  giyen  by  the  best  nui'ses  is  rarely  to  be  trusted.  The  varieties  of 
loose  stool  are  elsewhere  considered.  Food  vomited  sour  from  the  stom- 
ach indicates  a  catarrhal  state  of  the  gastric  mucous  membrane.  Much 
mucus  mixed  vrith  the  ejected  matters  is  also  a  sign  of  the  same  condition. 
Vomiting  is  not,  however,  always  a  symptom  of  distress.  An  infant  who 
has  swallowed  too  lai'ge  a  quantity  of  milk,  or  has  taken  his  bottle  too 
hastily,  will  often  eject  a  part  of  the  meal ;  but  in  such  a  case  there  is 
nothing  offensive  about  the  matters  thi'own  up  and  the  child  himself  shows 
no  sign  of  distress. 

In  the  treatment  of  disease  in  early  hfe  the  actual  administration  of 
physic  is  of  less  importance  than  a  careful  regulation  of  the  diet  and  at- 
tentive nursing.  It  is  the  duty  of  the  practitioner  to  see  that  no  impedi- 
ment is  thi'own  in  the  way  of  the  proper  working  of  the  various  functions  ; 
that  the  stomach  is  supplied  with  food  it  can  digest,  that  the  skin,  the  kid- 
neys, and  the  bowels  are  encoui-aged  to  carry  on  theii-  duties  as  emuncto- 
ries,  that  the  au'  of  the  room  is  kept  pui-e  and  frequently  renewed,  and  is 
moreover  maintained  at  a  suitable  temiDcrature. 

Febrile  attacks  are  very  common  in  childhood,  and  if  the  temperature 
is  high  (i.e.,  above  100°),  which  it  may  be  from  very  slight  and  transient 
causes,  the  child  should  be  confined  to  his  bed  and  kept  there  as  long  as 
the  pyrexia  continues.  In  aU  forms  of  fever  the  child  should  occupy  a 
large,  well-ventilated  room.  This  should  be  kept  at  the  temperatui'e  as 
nearly  as  possible  of  65^,  and  every  care  should  be  taken  to  maintain  the 
ail'  of  the  room  fi-esh  and  pure.  Still,  no  draught  must  be  allowed.  If 
the  mndow  is  ojDen  the  patient  must  be  scrupulously  jDrotected  from  aU 
cuiTents  of  air.  No  discharges  from  the  body,  soiled  hnen,  dii'ty  plates  or 
dishes  should  be  allowed  to  remain  in  the  sick-room  a  moment  longer  than 
is  necessary  ;  and  in  the  case  of  the  infectious  fevers  the  excreta  must  be 
disinfected  at  once,  and  the  soiled  sheets  and  other  linen  steeped  after  re- 
moval in  a  tub  of  water  containing  carbohc  acid  or  other  disinfectant. 

All  noise  and  bustle  must  be  prohibited  ;  and  few  persons  must  be  al- 
lowed at  the  same  time  in  the  room.  If  the  child  require  amusement,  he 
must  be  allowed  only  such  unexciting  diversions  as  books,  pictures,  and 
quiet  games  can  afford.  His  food  should  be  of  a  hght,  unstimulatiag  kind, 
such  as  thin  broth,  milk,  light  puddings,  and  jelly.  His  thirst  may  l^e 
assuaged  at  frequent  intervals,  care  being  taken,  however,  that  only  small 
quantities  of  fluid  are  allowed  on  each  occasion.  Too  large  c[uan titles  of 
lic[uid  distend  the  stomach,  impau'  the  digestion,  and  heljD  to  promote 
diarrhcea.  This  is  a  fact  of  some  moment  in  the  treatment  of  diseases 
where  pui'ging  is  a  common  symptom,  as  measles  and  t;\-iDhoid  fever.  It 
is  advisable  to  make  use  of  a  small  glass  holding  about  two  ounces,  for  the 
child  \\-iU  be  usually  satisfied  if  allowed  to  drain  this  to  the  bottom.  As 
the  patient  grows  weaker  and  requires  more  decided  support,  he  may  be 
given  pounded  underdone  mutton,  strong  beef-essence,  yolks  of  egg,  and, 
if  stimulants  are  required,  the  brandy-and-egg  mixture  of  the  British  Phar- 
macopoeia. 

In  cases  where  deglutition  is  difficult  or  imjoossible,  as  in  infantile  teta- 
nus or  the  paralysis  which  follows  diphtheria,  and  in  all  cases  where  ffom 
wilfulness  or  incapacity  an  adecjuate  sujDply  of  food  is  not  taken,  it  may 


INTEODUCTOEY   CHAPTEE.  15 

be  necessary  to  feed  the  child  through  a  tube  introduced  into  the  stomach. 
This  operation  is  best  performed  by  passing  an  elastic  catheter  through 
the  nose  and  down  the  gullet.  The  instrument  is  more  conveniently  in- 
troduced through  the  nose  than  through  the  mouth.  Less  oj)position  is 
aroused  by  this  method,  and  little  or  no  irritation  appears  to  be  set  up  in 
the  nasal  passages.  The  tube  '  properly  oiled  must  be  directed  along  the 
floor  of  the  nasal  cavity  into  the  pharynx,  and  can  be  then  readily  pushed 
down  the  gullet  into  the  stomach.  If  it  catch  against  the  top  of  the  lar- 
ynx, a  spasmodic  cough  is  excited.  The  instrument  must  be  then  with- 
drawn slightly  and  again  pushed  forwards.  There  is  httle  difficulty  about 
the  operation  if  the  child's  head  be  directed  well  backwards.  By  this 
means  liquid  food  can  be  administered  regularly  ;  and  in  certain  diseases 
— especially  infantile  tetanus,  where  nourishment  is  urgently  needed  and 
is  indispensable  to  success  in  the  treatment — feeding  through  the  nose 
becomes  a  valuable  addition  to  our  resources. 

If  the  power  of  swallowing  be  unimpaired,  a  simpler  method  may  be 
adopted.  In  such  a  case  it  is  only  necessary  to  carry  the  food  into  the 
fauces.  If  other  means  are  not  at  hand,  fluid  nourishment  may  be  poured 
directly  into  the  nostril  as  the  child  lies  in  his  cot.  The  liquid  at  once 
gravitates  to  the  back  of  the  throat  and  is  swallowed  as  it  reaches  the 
pharynx.  If  preferred,  the  fluid  may  be  injected  through  a  short  caout- 
chouc tube  passed  through  the  nose  to  the  upper  part  of  the  gullet.  In 
most  of  these  cases,  however,  the  simple  and  ingenious  method  devised  by 
Mr.  Scott  Battams,^  and  introduced  by  him  into  the  East  London  Chil- 
dren's Hospital,  may  be  resorted  to.  In  the  case  of  weakly  or  collapsed 
infants  this  method  is  invaluable  ;  but  children  of  all  ages,  if  prostrated 
by  illness,  can  take  nourishment  more  conveniently  by  this  means  than  by 
any  other.  The  apparatus  is  of  the  simplest  kind,  and  consists  merely  of 
an  ordinary  glass  syringe  with  a  piece  of  India-rubber  tubing,  four  inches 
long,  slipped  over  the  nozzle.  The  syringe  is  filled  in  the  ordinary  way 
by  drawing  up  fluid  through  the  tubing.  The  tube  is  then  passed  between 
the  child's  lips  towards  the  back  of  the  tongue  and  the  contents  of  the 
syringe  are  slowly  discharged  into  the  mouth. 

These  diflerent  methods  of  feeding  are  all  useful.  The  stomach-tube 
passed  through  the  nose  should  be  employed  in  all  cases  where  deglutition 
is  impaired,  from  whatever  cause — either  from  inflammatory  conditions  of 
the  throat,  from  loss  of  excitability  of  the  pharynx  owing  to  cerebral  dis- 
ease or  narcotic  poisoning,  or  from  paralysis,  as  after  diphtheria.  The 
syringe-feeder  just  described  may  be  used  in  cases  of  great  weakness  and 
prostration,  and  in  all  cases  where  the  power  of  swallowing  is  not  inter- 
fered with. 

The  question  of  reducing  temperature  when  this  rises  to  a  dangerous 
height  is  an  important  one.  Children  often  bear  a  high  temperature  well, 
and  it  is  not  always  easy  to  say  what  degree  of  heat  constitutes  hyperpyrexia 
in  a  child.  When  the  fever  is  due  to  a  septic  cause  it  is  perhaps  less  well 
borne  than  when  it  is  the  consequence  merely  of  a  local  inflammation.  In 
any  case  if  the  temperature  rise  above  106°,  or  if  the  patient  seem  to  be 
distressed  by  a  less  degree  of  heat,  it  is  advisable  to  sponge  the  surface  of 
the  body  with  tepid  water.     If  the  fever  be  not  reduced  by  this  means,  the 

'  The  best  tube  to  use  is  a  vulcanised  india-rubber  catheter  sufficiently  stiff  not  to 
kink.     A  No.  7  is  the  most  useful  size. 

^Mr.  Battam's  paper  on  the  Forced  Feeding  of  Children,  in  the  Lancet  of  June 
16  and  28,  1883,  in  which  the  various  methods  of  feeding  are  described,  is  full  of  in- 
terest and  instruction. 


16  ,  DISEASE   IIS"   CHILDEElSr. 

child  should  be  placed  in  a  bath  of  the  temperature  of  75°,  and  be  kept 
there  until  the  pyrexia  undergoes  a  sensible  diminution.  Usually  spong- 
ing the  surface  will  reduce  the  bodily  heat  by  several  degrees,  to  the  im- 
mediate relief  of  the  patient.  In  cases  of  inflammatory  diarrhoea,  even  in 
babies  of  a  few  months  old,  the  temperature  often  rises  to  109°  or  110°, 
and  the  child  passes  into  a  state  of  profound  depression.  When  this  hap- 
pens death  is  inevitable  unless  the  pyrexia  can  be  quickly  reduced  ;  and 
tepid  bathing  is  often  successful  in  greatly  retarding  if  it  do  not  actually 
prevent  a  fatal  issue  to  the  illness. 

In  all  forms  of  fever  the  comfort  of  the  j)atient  is  greatly  promoted  by 
the  use  of  two  cots — one  for  the  day,  the  other  for  the  night.  In  cases  of 
pericarditis  with  copious  effusion,  in  the  later  period  of  typhoid  fever, 
and  in  other  instances  where  the  debihty  is  extreme  or  the  action  of  the 
heart  hampered  and  feeble,  the  change  from  one  cot  to  the  other  must  be 
made  with  every  precaution  to  spare  the  child  all  spontaneous  movement, 
and  to  keep  him  in  a  recumbent  posture. 

In  the  treatment  of  disease  in  early  life  the  remedies  at  our  command 
are  the  same  as  are  useful  for  similar  conditions  in  the  adult.  On  account 
however,  of  the  impressible  nervous  system  in  the  young  subject  external 
applications  are  of  greater  importance  in  childhood  than  they  become  in 
after  years.  Amongst  the  remedies  of  the  greatest  value  baths  form  a 
class  of  no  little  importance.  According  to  the  temperature  of  the  water 
employed  the  bath  becomes  a  sedative,  a  stimulant,  or  a  tonic,  as  may  be 
required  ;  and  in  these  different  shapes  is  often  resorted  to  with  great  ad- 
vantage. The  usefulness  of  tepid  bathing  in  reducing  fever  has  ah'eady 
been  referred  to. 

The  tvarm  bath  (80°  to  85°  Fah.)  is  very  useful  in  cases  of  convulsions 
or  great  irritability  of  the  nervous  system,  shown  by  agitation,  restlessness, 
spasm  or  disturbed  sleep.  It  calms  the  excitement,  allays  spasm,  pro- 
motes the  action  of  the  skin,  and  induces  sleep.  On  account  of  its  diapho- 
retic effect  warm  bathing  is  of  great  service  in  cases  of  Bright's  disease.  In 
infants  the  warm  bath  has  a  sensible  influence  in  promoting  the  action  of  the 
bowels,  and  in  cases  of  constipation  is  often  a  valuable  addition  to  purga- 
tive medicines.  The  child  should  remain  from  ten  to  twenty  minutes  in 
the  warm  water. 

The  hot  hath  (95°  to  100°  Fah.)  is  of  great  value  as  a  stimulant  where 
there  is  sudden  and  severe  prostration,  such  as  occurs  in  cases  of  profuse 
diarrhcea,  urgent  vomiting,  shock,  or  other  cause  which  induces  a  temporary 
depression  of  the  vital  energies.  When  employed  in  this  way  as  a  stimu- 
lant the  child  must  not  remain  too  long  in  the  water  or  the  stimulant  effect 
will  pass  off  and  be  succeeded  by  depression.  For  an  infant  three,  and 
for  an  older  child  five  minutes  will  be  sufficient  immersion.  The  patient 
can  then  be  removed,  wiped  rapidly  dry,  and  laid  between  blankets  with  a 
hot  bottle  to  his  feet.  This  bath  may  be  made  more  stimulating  hj  the 
addition  of  mustard.  Flour  of  mustard,  in  the  proportion  of  one  ounce 
to  each  gallon  of  water,  is  mixed  up  with  a  little  warm  water  into  a  thin 
paste  and  placed  in  a  piece  of  mushn.  This  is  squeezed  in  the  hot  w^ater 
until  the  latter  becomes  strongly  sinapised.  So  prepared,  the  mustard 
bath  is  an  important  remedy  in  cases  of  prostration  and  collapse.  The 
child  should  be  held  in  the  bath  until  the  arms  of  the  attendant  supporting 
him  begin  to  tingle. 

The  cold  douche  is  a  tonic  of  the  utmost  value.  It  must,  however,  be 
employed  with  discretion,  for  the  patient  if  weakly  seldom  obtains  a  proper 
reaction  unless  special  precautions  be  taken.     If  the  child  look  blue  or 


INTEODUCTORY   CHAPTER.  17 

feel  chilly  after  tiie  bath,  the  shock  to  the  system  has  been  too  violent. 
For  a  weakly  child  the  cold  douche  should  always  be  given  in  the  follow- 
ing way  :  On  rising  from  his  bed  the  child  is  thoroughly  shampooed  all 
over  the  body,  using  steady  frictions  especially  to  the  back  and  loins. 
His  skin  being  thus  stimulated  and  prepared  to  resist  the  shock  of  the 
cold  water,  the  patient  is  made  to  sit  in  a  few  inches  of  water  as  hot  as  he 
can  conveniently  bear  it,  and  then  immediately  a  pitcher  of  cold  water  (55° 
to  60°)  is  emptied  over  his  shoulders.  He  is  then  at  once  removed,  and 
well  rubbed  with  a  rough  towel  to  assist  reaction.  In  winter  the  bath, 
should  be  placed  before  the  fire,  and  every  care  should  be  taken  to  make 
the  process  a  rapid  one.  The  shampooing  will  occupy  from  ten  to  fifteen 
minutes,  but  the  douche  should  be  over  in  as  many  seconds.  It  is  well  to 
allow  the  child  a  drink  of  milk  or  a  biscuit  before  beginning  the  process  ; 
and  when  dried  the  child  may  return  to  his  bed  for  a  short  time  if  thought 
desirable  ;  but  after  one  or  two  repetitions  of  the  bath  this  precaution  will 
be  unnecessary.  So  employed,  the  bath  must  be  regarded  purely  as  a 
therapeutic  agent,  and  not  as  a  cleansing  process.  The  body  may  be  washed 
in  the  ordinary  way  at  night  before  the  child  is  put  to  bed. 

The  cold  douche  is  of  great  service  in  all  cases  of  weakness,  whether 
this  be  due  to  acute  or  chronic  illness,  and  is  only  inadmissible  if  the  lungs 
are  actively  diseased  or  there  is  fever.  It  is  especially  useful  in  cases  of 
long-standing  derangement  and  in  the  scrofulous  cachexia,  and  may  be 
recommended  without  hesitation  for  children  of  very  fragile  appearance. 
In  addition  to  its  tonic  effect  the  bath  has  another  valuable  quality  in  that 
it  strengthens  the  resisting  power  of  the  body  against  changes  of  tempera- 
ture, and  lessens  the  susceptibility  to  cold. 

The  hot  and  mustard  baths  may  be  considered  in  the  light  of  counter- 
irritants,  which  act  through  the  surface  generally  and  produce  a  powerful 
stimulating  effect  upon  the  flagging  nervous  system.  A  similar  means  of 
rousing  the  vital  energies  consists  in  the  employment  of  stimulating  lini- 
ments. Thus,  in  cases  of  atelectasis,  energetic  frictions  with  a  strong  irritat- 
ing application  will  often  enable  the  child  to  expand  the  coUapsed  portion 
of  lung,  and  thus  save  him  from  immediate  danger.  In  many  varieties  of 
local  disease,  counter-irritants  are  of  extreme  service.  They  may  be  used 
in  the  form  of  blisters,  mustard  poultices,  and  painting  with  the  tincture 
or  liniment  of  iodine.  The  kind  of  application  best  suited  to  each  particu- 
lar case  will  be  described  in  the  proper  place.  It  may  be  here  stated,  how- 
ever, that  blisters  must  be  used  to  children,  especially  to  young  infants, 
wdth  great  caution  ;  and  Bretonneau  recommends  that  in  every  case  a  thin 
layer  of  oiled  paper  should  be  interposed  between  the  vesicating  surface 
and  the  skin.  A  blister  applied  too  long  leads,  as  M.  Archambault  has 
pointed  out,  to  a  sore  equivalent  to  a  burn  of  the  third  degree,  anc^  heals 
very  slowly.  Caution  in  the  application  of  the  more  powerful  counter- 
irritants  is  especially  to  be  observed  when  the  patient  is  very  young,  or  is 
the  subject  of  defective  nutrition  or  of  chronic  disease.  In  such  cases  ob- 
stinate ulceration  may  be  set  up,  or  gangrene  of  the  skin  may  be  induced, 
not  to  mention  the  exhausting  effect  upon  a  weakly  patient  of  the  pain 
caused  by  the  application  of  the  irritant,  and  the  effusion  of  a  higlily  albu-^ 
minous  fluid.  If  diphtheria  be  epidemic  in  the  neighbour-hood,  bhsters. 
should  never  be  employed,  as  the  resulting  sore  may  become  covered  with 
the  diphtheritic  exudation.  For  a  young  child  a  blister  should  be  of  small 
size  and  ought  quickly  to  be  removed.  Under  twelve  months  of  age  can- 
tharidine  applications  should  rai-elybe  resorted  to.  If  used  during  the: 
second  year,  the  blister  may  remain  in  contact  with  the  skin  for  an  hour 
2 


18  DISEASE  IIS-   CHILDEEN. 

and  a,  half.  For  each  additional  year  of  life  a  further  half  hour  may  be 
added  to  the  length  of  time  the  application  may  be  employed  ;  so  that  for 
a  child  of  four  years  of  age  the  blister  may  remain  two  hours  and  a  half  ; 
for  a  child  of  five,  three  hours.  If  vesication  has  not  been  produced  when 
the  irritant  is  removed,  a  warm  bread-and-water  poultice  will  soon  cause 
it  to  appear.  The  fluid  can  then  be  let  out  and  cotton  wadding  applied. 
No  other  dressing  will  be  required. 

Amongst  internal  remedies  alcoholic  stimulants  take  a  high  place.  Chil- 
dren reduced  by  severe  illness  respond  well  to  the  action  of  alcohol,  and  a 
few  timely  doses  of  this  medicine  have  often,  in  a  doubtful  case,  turned 
the  scale  in  favour  of  recovery.  So,  also,  weakly  children  with  poor  appe- 
tites and  feeble  digestions  often  benefit  greatly  by  an  allowance  of  wine 
with  their  principal  meal.  Stimulants  may  be  prescribed  for  the  youngest 
infants,  and  in  cases  of  great  weakness  may  be  repeated  at  frequent  inter- 
vals. When  the  patient  is  very  young  and  requires  energetic  stimulation, 
a  small  quantity  of  wine  or  brandy  often  repeated  is  to  be  preferred  to  a 
larger  quantity  given  at  more  distant  intervals.  The  remedy  should  not 
be  continued  too  long.  It  must  be  remembered  that  a  stimulant  is  not  a 
tonic.  It  is  given  for  an  immediate  purpose,  and  should  be  withdrawn 
or  greatly  reduced  in  quantity  when  the  object  has  been  attained. 

Tonics,  such  as  quinine,  iron,  the  mineral  acids,  and  vegetable  bitters, 
are  also  of  great  value  in  the  treatment  of  disease  in  the  child.  But  they 
require  to  be  given  with  judgment,  and  must  not  be  administered  indis- 
criminately because  the  patients  look  weak  and  pale.  A  feeble-looking, 
pallid  child,  is  not  always  to  be  benefited  by  iron  and  other  tonics.  Such 
a  condition  is  often  dependent  upon  a  chronic  form  of  dyspepsia,  the  result 
of  repeated  catarrhs  of  the  stomach.  In  such  cases  a  proper  selection  of 
food,  and  alkalies  given  to  diminish  the  secretion  of  mucus  and  neutralise 
acidity,  will  soon  produce  a  marked  improvement  in  cases  where  tonics 
have  been  given  without  good  result.  It  is  only  when  local  derangement 
has  been  remedied  that  the  tonic  becomes  useful.  The  same  remarks 
apply  to  cod-hver  oil.  This  valuable  remedy  is  inappropriate  so  long  as 
any  digestive  derangement  remains  uncorrected.  When  the  alimentary 
canal  has  been  brought  into  a  healthy  state,  the  oil  is  of  enormous  service, 
and  may  be  given  in  suitable  doses  to  the  youngest  infants.  It  must  be 
remembered,  however,  that  the  power  of  digesting  fats  in  early  life  is  not 
great.  Under  twelve  months  of  age  ten  drops  will  be  a  sufficient  quantity 
to  be  given  on  each  occasion  ;  and  if  any  oil  is  noticed  undigested  in  the 
stools,  even  this  smaU  quantity  must  be  reduced. 

In  cases  where,  although  nourishment  is  urgently  required,  oil  cannot 
be  digested,  the  remedy  may  be  rubbed  into  the  skin.  The  external  appli- 
cation of  oil  is  of  service  in  all  cases  of  chronic  weakness  and  wasting.  It 
is  useful  not  only  as  a  means  of  introducing  nourishment,  but  also  as  an 
agent  in  promoting  the  action  of  the  skin,  which  in  most  forms  of  chronic 
derangement  is  apt  to  become  inactive  and  dry.  The  appHcation  should 
be  made  at  night.  Any  oil  is  useful  for  the  purpose,  and  it  is  not  indis- 
pensable that  cod-liver  oil  be  employed.  The  oil  should  be  warmed  and 
then  applied  to  the  whole  body  with  a  piece  of  fine  sponge.  At  the  same 
time  if  there  is  any  special  weakness  in  the  back  or  elsewhere,  vigorous 
friction  with  the  oil  may  be  used  to  the  part  it  is  desired  to  strengthen. 
Afterwards  the  child  should  be  put  to  bed  in  a  flannel  night-dress. 

In  the  administration  of  drugs  to  young  subjects,  we  must  remember 
that  the  dose  is  not  always  to  he  calculated  according  to  the  age  of  the 
child,  but  that  children  have  a  curious  tolerance  for  some  remedies  and  as 


ijn^teoductory  chapter.  19 

curious  a  susceptibility  to  others.  Opium,  it  is  well  known,  should  be 
given  with  caution.  The  remedy  is,  however,  of  extreme  value,  and  if  care 
be  taken  to  begin  with  only  a  small  quantity,  and  to  postpone  a  second 
dose  until  the  effect  of  the  first  has  been  ascertained,  no  ill  effects  can  pos- 
sibly be  produced  by  the  narcotic.  Thus,  for  a  child  of  twelve  months  old 
suffering  from  purging,  if  one  drop  of  laudanum  has  not  produced  drowsi- 
ness, a  second  may  be  given  in  sis  hours'  time  ;  and  the  remedy  will  be  weU 
borne  three  times  a  day. 

Belladonna  can  be  taken  by  most  children  in  large  quantities.  Some- 
times the  characteristic  rash  is  produced  by  a  small  dose,  but  a  much 
larger  quantity  wiU  be  required  to  dilate  the  pupil,  and  a  further  consid- 
erable increase  before  we  can  produce  dryness  of  the  throat  or  other 
physiological  effect  of  the  drug.  It  is  often  necessary  to  push  the  dose  so 
as  to  produce  dilatation  of  the  pupil.  Many  cases  of  nocturnal  inconti- 
nence of  urine  show  no  sign  of  yielding  until  some  symptoms  are  pro- 
duced indicating  that  the  system  is  responding  to  the  action  of  the  remedy. 
A.  child  of  twelve  months  old  wiU  usually  take  fifteen,  twenty,  or  more  drops 
of  the  tincture  of  belladonna  three  times  a  day  ;  and  often  we  can  push  the 
dose  at  this  age  far  beyond  this  limit. 

Besides  belladonna  children  bear  well  quinine,  digitalis,  arsenic,  lobelia, 
and  many  other  remedies.  Mercury  rarely  salivates  a  child,  but  has  often 
a  ]30werful  effect  in  deteriorating  the  quality  of  the  blood.  A  child  is 
usually  left  excessively  pale  at  the  end  of  a  course  of  this  drug. 

On  account  of  the  frequency  of  digestive  disturbances  and  the  tendency 
to  acidity  in  early  hfe,  alkalies  form  a  very  valuable  class  of  remedies.  A 
dose  of  bicarbonate  of  soda  or  potash  neutralises  acidity,  checks  hyper- 
secretion of  mucus,  and  if  given  with  a  few  drops  of  spirits  of  chloroform 
and  an  aromatic,  stops  fermentation,  dispels  flatus,  and  reduces  spasm.  In 
all  varieties  of  dyspepsia  in  the  child,  and  in  many  forms  of  looseness  of 
the  bowels,  this  combination  is  of  the  utmost  value. 

One  word  may  be  said  with  reference  to  the  abuse  of  aperient  medi- 
cines which  is  so  common  in  the  nursery.  Delicate  children  have  often 
died  from  the  effects  of  a  drastic  purge,  and  many  a  case  of  typhoid  fever 
has  received  a  fatal  impulse  by  this  means.  An  aperient  is  the  common 
domestic  remedy — the  corrective  to  be  administered  at  once  upon  the 
slightest  appearance  of  illness  ;  and  prescribing  chemists  invariably  recom- 
mend it  as  an  antidote  for  every  ill.  But  constipation  is  only  one  of  many 
causes  of  malaise,  and  to  irritate  the  bowels  unnecessarily  with  a  strong 
purgative  powder  may  do  serious  injury  to  a  weakly  child. 


Part  1. 
THE  ACUTE  INFECTIOUS  DISEASES. 


CHAPTER  I. 

MEASLES. 


Measles  (rubeola  or  morbili)  is  one  of  the  commonest  infectious  fevers  to 
•wMch  children  are  liable  ;  and  few  persons  arrive  at  adult  years  without 
having  suffered  fit-om  an  attack.  It  affects  children  of  all  ages,  and  is  far 
from  uncommon  in  infants.  Scattered  cases  of  measles  may  be  found 
almost  at  any  time  in  large  towns,  but  at  certain  periods  of  the  year  the 
complaint  becomes  epidemic.  These  epidemics  vary  curiously  in  severity 
and  in  the  predominance  of  particular  symptoms.  One  may  be  signaHzed  by 
a  high  percentage  of  mortality.  In  another  vomiting  may  be  a  prominent 
and  distressing  feature.  In  a  third  the  catarrhal  phenomena  may  be 
unusually  slight ;  or  again,  they  may  be  severe  out  of  all  proportion  to  the 
intensity  of  the  rash.  When  fatal,  measles  is  so  generally  through  its  com- 
plications. It  rarely  kills  by  the  intensity  of  the  general  disease.  Still,  in 
some  cases  we  meet  with  epidemics  in  which  the  disease  tends  to  assume 
an  asthenic  type.  In  these  the  mortahty  is  high.  The  fatal  cases  are 
marked  by  early  and  extreme  prostration.  The  patient  seems  overwhelmed 
by  the  violence  of  the  attack,  and  dies  before  any  comphcation  has  had 
time  to  manifest  itself.  As  a  rule,  one  attack  protects  against'  a  second,  but 
cases  where  the  disease  has  occurred  two  and  even  three  times  are  not  mi- 
common. 

The  contagious  principle  of  measles  is  apparently  communicated  by 
means  of  the  breath.  It  is  said  to  be  volatile,  and  to  be  capable  of  adher- 
ing to  clothing.  According  to  Meyer,  it  is  easily  removed,  as  the  mere 
airing  of  clothes  is  sufficient  to  disinfect  them.  Messrs.  Braidwood  and 
Vacher  have  examined  the  expired  air  of  measles  patients  by  making  them 
breathe  through  glass  tubes  coated  in  the  interior  with  glycerine.  On 
examination  afterwards  with  the  microscope,  the  glycerine  showed  in  every 
case  numerous  sparkling  colourless  bodies,  some  spherical,  others  more 
elongated  with  sharpened  ends.  They  were  most  abundant  during  the 
first  and  second  days  of  the  eruption.  As  a  negative  test,  the  breath  from 
healthy  children,  and  children  suffering  from  scarlatina  and  typhus,  was  also 
examined,  but  without  any  result. 


22  DISEASE   IN   CHILDEEjST. 

The  infection  of  measles  begins  at  the  very  beginning  of  the  catarrhal 
stage,  and  lasts  for  some  time  after  the  rash  has  faded.  Dr.  Squire  is  of 
opinion  that  thi-ee  weeks  ought  to  elapse  before  the  patient  can  be  con- 
sidered free  from  all  chance  of  communicating  the  disease. 

Morbid  Anatomy. — The  post-mortem  appearances  in  cases  of  death  from 
this  complaint  are  those  of  the  complication  to  which  the  fatal  termination 
is  owing.  In  cases  where  the  child  has  died  early  fi-om  the  severity  of  the 
disease,  little  is  found  except  that  the  blood  is  dark  coloured,  deficient  in 
fibrine,  and  coagulates  imperfectly.  There  is  also  hypostatic  congestion  of 
the  lungs  and  hypersemia  of  the  mucous  membranes  and  organs  generally, 
with  extravasation  into  then-  substance.  The  spleen  and  lymphatic  glands 
are  often  swollen.  Sections  of  the  skin  made  on  the  sixth  day  of  the  erup- 
tion were  examined  by  Messrs.  Braidwood  and  Vacher.  There  was  swelling 
of  the  corium,  and  thickening  of  the  rete  Malpighii  from  great  proliferation 
of  cells,  which  extended  along  the  hair  and  sweat-ducts  into  the  glands. 
Sparkling,  colourless,  spheroidal,  and  elongated  bodies,  similar  to  those 
discovered  in  the  breath,  were  found  in  the  portion  of  the  true  skin  lying 
next  to  the  rete,  in  the  lungs,  and  in  the  liver.  In  aU  these  situations  these 
bodies  were  mixed  with  other  bodies,  spindle-shaped,  staff-shaped,  and 
canoe-shaped.     They  appeared  to  be  albuminoid  in  character. 

Symptoms. — The  incubation  period  of  measles  is  ten  or  twelve  days. 
The  complaint  then  begins  with  the  signs  of  catarrh.  The  patient  is 
thought  to  have  a  cold :  he  sneezes,  coughs,  and  his  eyes  look  watery  and 
red.  With  this  there  is  fever  ;  often  headache  ;  the  appetite  is  poor ;  and 
the  child  generally  feels  ill  and  is  languid.  The  catarrhal  symptoms  in- 
crease ;  the  nose  may  bleed  ;  there  is  some  soreness  of  throat ;  and  the 
patient  is  often  hoarse,  and  complains  of  soreness  in  the  chest.  If  the 
fever  is  high,  the  child  may  wander  at  night  and  be  very  restless.  Some- 
times the  attack  is  ushered  in  by  a  convulsive  fit,  and  occasionally  the 
convulsions  recur  later  on,  either  before  the  rash  has  appeared  or  after- 
wards. The  skin  is  generally  moist,  although  the  temperature  rises  to  102° 
or  103°,  or  even  higher.  In  a  case  which  came  under  my  own  notice  at 
this  stage,  a  boy  was  seized  with  diarrhoea  on  July  10th.  His  temperature 
on  that  evening  was  102°.  The  next  morning  it  was  103°,  but  the  bowels 
acted  five  times  in  the  course  of  the  day,  and  in  the  evening  it  had  fallen  to 
101.4°.  His  pulse  at  that  time  was  160,  and  his  respirations  were  48.  On 
the  evening  of  the  12th  the  temperature  was  102°,  and  on  the  morning  of 
the  13th,  when  the  rash  appeared,  the  mercury  mai'ked  103°  ;  pulse,  124  ; 
respirations,  48.  Although  pyrexia  is  the  rule  during  the  pre-eruptive  stage, 
in  exceptional  cases  the  temperature  may  be  normal.  I  have  known  this 
to  be  the  case  in  two  instances.  In  each  of  these  young  children  the 
bodily  heat,  both  morning  and  evening,  for  the  four  days  before  the  appear- 
ance of  the  rash  was  between  98°  and  99° ;  and  when  the  eruption  began 
the  temperatui-e  only  rose  to  101°.  The  rash  was  typical  in  character, 
and  all  the  catarrhal  symptoms  were  present. 

The  digestive  organs  are  usually  deranged,  partly  on  account  of  the 
fever  ;  partly  on  account  of  the  mucous  membrane  of  the  stomach  sympa- 
thizing with  the  general  derangement.  The  tongue  is  thickly  furred; 
there  is  often  vomiting  ;  and  the  bowels  may  be  relaxed. 

The  characteristic  eruption  appears  as  a  rule  on  the  fourth  day,  haying 
been  preceded  by  three  clear  days  of  catarrh  and  fever.  In  rare  cases  it  is 
seen  on  the  third  day  ;  or,  again,  it  may  be  delayed  until  the  fifth,  or  even 
longer ;  but  these  are  exceptions.  There  is  seldom  any  appreciable  sub- 
sidence of  the  fever  on  the  appearance  of  the  rash.     Indeed,  the  opposite 


MEASLES — SYMPTOMS.  23 

is  usually  the  case.  Both  the  fever  and  the  catarrhal  symptoms  seem  to 
be  intensified,  when  the  rash  comes  out ;  and  if  diarrhoea  have  not  been 
present  before,  the  bowels  generally  become  loose. 

The  emption  is  first  seen  about  the  chin,  the  temples,  and  the  fore- 
head, as  slightly  elevated  spots  of  a  yellowish  red  colom-,  which  disappear 
imder  pressure.  Small  at  first,  they  soon  reach  one  and  a  half  or  two 
lines  in  diameter,  and  have  irregular  edges.  From  the  face  the  rash  soon 
spreads  to  the  trunk  and  limbs,  and  in  twenty-four  hoTirs  is  generally 
found  to  cover  the  whole  sui'face  of  the  body  and  extremities.  As  it 
spreads,  the  borders  of  neighbouring  spots  tmite  so  as  to  form  crescentic 
patches.  Between  these  the  skin  is  of  normal  coloui-,  unless  the  emption 
be  very  profuse,  in  which  case,  as  we  often  see  on  the  face,  the  junction  of 
the  closely  set  spots  may  produce  a  uniform  blush  over  a  considerable 
extent  of  surface. 

As  the  rash  becomes  more  completely  developed,  its  colour  grows  of  a 
deeper  red  ;  and  if  the  skin  be  very  moist,  vesicles  with  an  inflamed  base 
may  be  seen  scattered  over  the  surface.  A  child  with  the  eruption  fully 
out  and  the  catarrhal  symptoms  well  marked,  presents  a  very  character- 
istic appearance.  His  face  is  somewhat  swollen,  so  that  the  features  appear 
thick  and  coarse.  A  dull  red  flush  occupies  each  cheek  ;  and  the  forehead, 
mouth,  and  chin  are  speckled  over  with  the  crescentic  patches.  The  eyes 
are  red  ;  the  eyelids  congested  ;  and  the  upper  lip  is  excoriated  by  the 
copious  flow  of  thin  mucus  from  the  nose.  Often  crusts  of  dried  blood 
are  seen  about  the  nostrils,  for  epistaxis  is  a  very  common  sjonptom.  The 
rash  remains  at  its  height  for  about  twenty-four  or  forty-eight  hours,  and 
then  begins  to  fade.  The  colour  changes  again  to  a  yellowish  red,  and  in 
a  day  or  two  has  disappeared,  leaving  nothing  on  the  skin  but  a  faint  red- 
dish stain,  which  may  last  for  a  few  days  longer  before  the  normal  colour 
of  the  integument  is  completely  restored. 

There  are  varieties  in  the  rash.  Sometimes  the  spots  when  they  first 
appear  are  hard,  scattered,  and  prominent.  These  are  the  cases  which  are 
often  mistaken  for  variola.  Sometimes  the  eruption  does  not  completely 
disappear  under  pressure,  and  we  then  often  find  httle  points  of  extrava- 
sation from  rupture  of  small  capillaries  in  the  skin.  This  occurs  in  cases 
where  there  is  great  hypersemia  of  the  cutaneous  tissue.  It  is  of  no  bad 
augury.  A  further  degree  of  the  same  phenomenon  is  sometimes  seen  in 
which  the  eruption  grows  darker  and  darker  until  it  has  acquired  a  deep 
purple  tint.  This  is  also  the  consequence  of  ruptiu-e  of  distended  cutane- 
ous capillaries.  Such  a  rash  does  not  disappear  with  presstu-e,  and  re- 
mains visible  for  a  much  longer  time  than  an  ordinary  eruption,  fading  very 
slowly. 

The  fever  and  catarrh  remain  at  their  height  until  the  rash  begins  to 
fade.  The  severity  of  the  catarrhal  symptoms  varies  very  much  in  difier- 
ent  epidemics  and  with  different  patients.  Sometimes  all  the  mucous 
membranes  seem  to  suffer  :  the  throat  is  sore  ;  the  ej^es  are  inflamed  ; 
there  is  deafness  fi'om  closure  of  the  Eustachian  tube,  and  the  inflammation 
may  even  spread  to  the  middle  ear  ;  vomiting  may  be  distressing,  and 
purging  severe  ;  a  mild  laryngitis  may  become  intensified  and  be  accom- 
panied by  spasm  (stridulous  laryngitis).  All  these  symptoms  are  usually 
greatly  reheved  when  the  eruption  begins  to  disappear  ;  and  if  there  be 
no  complication  sufficiently  serious  to  maintain  the  pyrexia,  the  tempera- 
ture falls  at  once  to  nearly  its  natural  level,  and  the  pulse  loses  much  of 
its  frequency. 

The  disappearance  of  the  rash  is  followed  by  a  fine  desquamation  of 


24  DISEASE  I]Sr   CHILDEEISr. 

the  skin.  The  peeling  differs  much  from  the  shedding  of  the  skin  which 
is  such  a  mai'ked  symptom  in  scarlatina.  The  epithehum  falls  in  fine  bran- 
like scales  which  are  often  almost  invisible  to  the  naked  eye,  so  that  this 
stage  not  unfrequently  passes  quite  unnoticed  by  the  attendants. 

In  an  uncompUcated  case  of  measles  the  chest  symptoms  are  usually 
mild.  The  cough  is  at  first  hard  and  hacking,  and  during  the  eruptive 
period  is  often  paroxysmal,  with  a  loud  barking  character.  After  the 
eruption  has  begun  to  fade,  the  cough  becomes  looser  and  less  frequent ; 
and  if  proper  care  be  taken  to  avoid  chills,  it  soon  ceases  to  be  heai'd.  The 
physical  signs  about  the  chest  are  those  of  pulmonaiw  catarrh.  One  con- 
sequence of  the  irritation  in  the  lungs  set  up  by  the  catai'rh  is  seldom 
absent,  especially  in  scrofulous  children.  This  is  enlargement  of  the 
bronchial  glands.  If  there  be  much  throat  affection,  there  may  be  a  simi- 
lar swelling  of  the  glands  at  the  angle  of  the  lower  jaw  and  at  the  sides  of 
the  neck. 

The  urine  during  the  fever  is  high  colored,  with  abundant  urates.  It 
may  contain  a  trace  of  albumen. 

In  some  epidemics  cases  are  seen  which  present  aU  the  characters  of 
the  complaint  with  the  one  exception  that  the  rash  is  absent.  These  are 
no  doubt  cases  of  ii-regular  measles.  Cases  have  been  also  described  in 
which  the  rash  is  jDresent,  but  the  catarrhal  symjDtoms  are  absent  (morbih 
sine  catarrho).  It  is  very  questionable  if  these  latter  are  classed  rightly 
under  the  head  of  measles. 

There  is  a  form  of  measles  which  is  distinguished  by  gTeat  prostration. 
Here  the  complaint  assumes  from  the  first  an  asthenic  type.  The  pulse  is 
small,  feeble,  and  very  frequent ;  the  respirations  are  rapid  ;  the  tongTie 
is  dry,  brovni,  and  thickly  furred  ;  the  temperature  of  the  body  is  high, 
although  the  extremities  feel  cold  to  the  touch  ;  and  the  child  is  dull  and 
seems  stupefied.  "W^hen  the  rash  comes  out,  it  is  imperfectly  developed 
and  of  a  dark  red  or  violet  hue.  The  skin  is  thickly  spotted  with  pe- 
techise.  Soon  the  pidse  becomes  so  rapid  that  it  can  only  be  counted 
with  difficulty  ;  the  muscles  become  tremulous  ;  there  is  muttermg  de- 
lirium, and  the  patient  dies  comatose  or  convulsed.  These  cases,  fortu- 
nately very  rare,  almost  invariably  prove  fatal.  They  are  generally  accom- 
panied by  hemorrhages  from  the  mucous  membranes  as  well  as  into  the 
skin.  Epistaxis  is  often  obstinate  ;  hsematuria  may  occtu' ;  and  after  death 
ecchymoses  may  be  found,  in  various  internal  organs. 

In  a  healthy  child  an  ordinary  attack  of  measles  is  a  mild  disorder  with 
little  severity  of  the  general  symptoms.  The  shai-pness  of  the  illness 
appears  to  be  determined  to  some  extent  by  the  constitutional  tendencies 
of  the  patient.  One  of  the  pathological  consequences  of  the  specific  fever 
being  the  active  congestion  of  the  mucous  membranes,  we  might  expect 
that  a  constitutional  state  in  which  there  is  ah-eady  a  predisposition  to 
derangement  of  these  membranes  would  determine  more  serious  symp- 
toms than  are  found  in  cases  where  there  exists  no  such  predisposition. 
Children  who  start  in  hfe  weighted  with  a  scrofulous  diathesis  are  genei*- 
aUy  bad  subjects  for  measles.  It  is  in  these  patients  that  catan'hal  symj)- 
toms  assume  such  prominence,  and  that  ophthalmia,  otitis,  and  the  other 
troubles  referred  to  above  are  so  liable  to  be  met  with.  Even  in  the 
mildest  cases  a  certain  dei^ression  foUows  the  subsidence  of  the  fever. 
The  temperature  sinks  to  a  subnormal  level,  and  the  pulse  is  very  slow 
and  intermittent. 

Of  all  the  eruj)tive  fevers  measles  is,  next  to  typhoid  fever,  the  one 
most  hable  to  return.     Manv  children  have  it  a  second  time,  often  after 


MEASLES — COMPLICATIOjSTS.  25 

only  a  short  interval ;  and  in  some  cases  the  second  attack  may  occur  at  so 
early  a  period  after  the  first  as  to  constitute  a  true  relapse.  Cases  are  met 
with  from  time  to  time  in  which  a  child  sickens  with  measles,  passes 
through  a  more  or  less  severe  attack,  recovers,  and  after  a  brief  interval  of 
convalescence  sickens  with  it  again — and  all  this  within  a  month. 

ComjDlications. — The  complications  which  may  render  an  attack  of  mea- 
sles troublesome  or  dangerous  have  been  ah"eady  in  part  referred  to.  As 
a  rule,  they  are  exaggerations  of  ordinary  or  extraordinary  symptoms  of 
the  complaint,  and  are  determined  either  by  the  character  of  the  epidemic, 
or  by  the  constitutional  peculiarities  of  the  patient. 

Convulsions  have  been  already  mentioned  as  occasionally  marking  the 
beginning  of  the  disease.  The  fits  may  be  repeated  several  times  ;  but 
when  limited  to  the  first  day  or  two  of  the  disorder,  although  alarming  to 
the  friends,  are  seldem  dangerous.  Should  they  be  repeated,  however, 
during  the  eruptive  stage,  they  must  be  regarded  with  more  anxiety,  for 
they  may  then  prove  fatal. 

Epistaxis,  a  common  symptom  and  generally  insignificant,  may  become 
profuse  and  exhausting.  In  severe  epidemics,  where  the  type  of  the  dis- 
ease is  a  low  one,  this  may  be  of  serious  moment.  In  any  case  it  must 
tend  appreciably  to  protract  the  period  of  convalescence. 

Diari'hoea  is  also,  as  a  rule,  a  symptom  of  little  consequence  ;  but  some- 
times the  mild  intestinal  catarrh  to  which  it  is  owing  may  be  converted 
into  a  real  cohtis.  The  stools  are  then  bloody  and  glairy,  and  there  is  colic 
with  great  tenesmus  and  pain  in  defecation. 

Laryngitis  is  a  marked  symptom  in  some  epidemics.  There  is  gener- 
ally a  certain  amount  of  hoarseness  early  in  the  disease  from  participation 
of  the  laryngeal  mucous  membrane  in  the  general  catarrh.  If  this  get 
worse  the  voice  becomes  husky  and  almost  extinct,  the  cough  hoarse  and 
"croupy,"  and  the  breathing  noisy  and  oj)pressed.  Great  alarm  is  natu- 
rally excited  by  this  condition  of  the  patient,  but  the  danger  is  really 
slight.  When  the  rash  begins  to  fade,  an  improvement  is  noticed  in  the 
thi'oat  symptoms  ;  and  they  often  disappear  quite  suddenly  when  the  tem- 
peratiore  falls.  It  must  not  be  forgotten  that  laryngitis  with  marked  spasm 
may  arise  quite  at  the  beginning  of  the  attack,  and  be  out  of  all  proportion 
to  the  signs  of  general  catarrh.  In  such  cases  the  existence  of  measles 
may  not  be  even  suspected  until  the  eruption  comes  out  and  discloses  the 
nature  of  the  disorder. 

Ophthalmia  and  otitis  are  less  common  symptoms.  When  these  occur, 
it  is  usually  in  children  of  marked  scrofulous  tendencies.  The  first  may 
form  an  obstinate  comphcation,  and  the  second  may  lead  to  very  serious 
consequences,     (See  Otitis.) 

Extension  of  the  bronchial  catarrh  to  the  smaller  tubes  is  a  very  grave 
accident.  It  is  common  in  babies  and  young  children,  and  almost  invari- 
ably proves  fatal,  for  in  early  life  collapse  of  the  lung  is  easily  provoked, 
and  once  estabhshed  quickly  terminates  the  illness.  The  first  indication 
of  danger  in  these  cases  is  oppression  of  the  breathing,  which  becomes 
very  rapid.  There  is  lividity  of  the  face,  and  the  countenance  is  haggard 
and  distressed.  With  the  stethoscope  we  hear  abundant  fine  subcrepitant 
rhonchus  over  both  sides  of  the  chest.  When  these  symptoms  are  present, 
veiy  active  measiu-es  must  be  taken  to  avert  a  fatal  issue  to  the  com- 
plaint. 

In  children  who  have  passed  the  age  of  twelve  months  catarrhal  pneu- 
monia is  a  more  frequent  comj)lication  than  the  preceding.  If,  in  any 
case,  on  the  fading  of  the  rash  the  temperature  undergoes  Little  diminu' 


26  DISEASE   IN   CHILD RElSr. 

tion,  we  may  expect  catarrhal  inflammation  of  the  lung's  to  be  present.  In 
such  a  case  the  child,  instead  of  becoming  better  and  more  kvely  as  the 
eruption  disappears,  seems  to  be  weaker  and  less  well  than  before.  His 
face,  the  swelling  having  subsided,  is  seen  to  be  pinched  and  haggard 
looking  ;  there  is  lividity  about  the  Hps  ;  the  nares  act  in  inspiration,  and 
the  breathing  is  quick  and  labored,  A  thermometer  in  the  axilla  marks 
about  102°,  seldom  higher.  The  patient  is  thirsty,  but  wiU  take  little  food. 
He  shows  no  interest  in  his  toys,  but  often  lies  picking  at  his  lips  and  fin- 
gers, indifferent  to  everything  but  his  own  uncomfortable  sensations.  Ex- 
amination of  the  chest  reveals  all  the  signs  of  acute  catan-hal  pneumonia. 

This  complication  may  also  come  on  at  an  earlier  stage,  when  the  erup- 
tion is  beginning  to  appear.  The  development  of  the  rash  is  then  retarded, 
or  the  exanthem  may  even  retrocede  with  great  aggravation  of  the  general 
symptoms.  CataiThal  pneumonia  is  fully  described  in  another  part  of  the 
volume,  but  it  may  be  mentioned  in  this  place  that  catarrhal  inflammation 
complicating  measles  often  runs  a  subacute  course,  and  persists  long  after 
all  signs  of  the  primary  complaint  have  disappeared.  It  may  end  in  death, 
in  complete  recovery,  or  may  become  a  chronic  lesion  forming  one  of  the 
varieties  of  pulmonary  phthisis. 

Sequelce. — The  sequelae  of  measles  are  constituted  in  part  by  the  above- 
mentioned  complications,  which,  like  catarrhal  jDueumonia,  may  become 
chronic  and  give  rise  to  trouble  and  anxiety.  Chronic  laryngitis '  and 
bronchitis  are  common  sequences.  Enlarged  bronchial  glands  often  re- 
main for  a  considerable  time  relics  of  the  disease  which  has  passed  away. 
Also,  it  may  again  be  repeated  that  in  children  of  scrofulous  tendencies  an 
attack  of  measles  may  hght  up  the  cachexia,  and  give  rise  to  any  or  all  of 
the  troubles  which  are  characteristic  of  that  constitutional  state.  Even 
children  who  are  free  from  this  unfortunate  predisposition  may  not  escape 
unhurt  from  the  attack.  A  condition  of  the  system  is  often  left  which  ap- 
pears to  favour  the  occurrence  of  secondary  disease  ;  and  whooping-cough, 
croup,  gangrene  of  the  mouth  and  vulva  may  occur  at  such  a  short  interval 
after  the  attack  that  they  cannot  but  be  looked  upon  as  direct  sequelae  of 
the  illness. 

Acute  tuberculosis  requires  special  mention  as  an  undoubted  and  fatal 
consequence  of  measles.  Measles,  indeed,  is  followed  by  true  tubercular 
disease  with  such  frequency  that  in  every  case  where  we  are  called  to  a 
child  who  has  been  left  weak  and  feverish  after  a  recent  attack  of  the  ex- 
anthema tons  disorder,  we  may  expect  him  to  be  the  subject  either  of 
catarrhal  jpneumonia  or  of  acute  tuberculosis. 

Diagnosis. — Before  the  stage  of  eruption  measles  is  not  easy  to  detect. 
A  severe  cold  in  the  child  is  often  accompanied  by  fever,  and  there  is 
nothing  in  the  catarrhal  symptoms  of  measles  Avhicli  can  be  considered 
peculiar  to  that  complaint.  If  such  symptoms  occur  at  a  time  when  we 
know  an  epidemic  to  be  raging,  the  probabilities  are  no  doubt  strongly  in 
favour  of  an  attack  of  this  disorder  :  but  in  the  opposite  case,  if  we  cannot 
ascertain  that  the  child  has  been  exposed  to  contagion,  it  is  wise  to  wait 
before  expressing  an  opinion.  Still,  we  should  never  forget  in  any  case  of 
high  temperature  in  a  child  with  signs  of  general  catarrh,   that  these  are 

'  In  all  cases  of  hoarseness  left  after  measles  the  vocal  cords  should,  if  possible,  be 
inspected  with  the  laryngoscope.  The  supposed  laryngitis  will  be  sometimes  found  to 
be  really  anaemia  of  the  larynx,  due  to  general  debility,  combined  with  weakness  of  the 
adductor  muscles,  which  fail  to  approximate  the  cords.  This  local  condition  may  be 
present  although  the  signs  of  general  anasmia  are  not  pronounced.  In  such  cases  we 
should  watch  the  child  anxiously  for  any  symptoms  indicative  of  tuberculosis. 


MEASLES — DIAGNOSIS — PROGNOSIS.  27 

the  early  symptoms  of  measles  ;  and  we  should  inquire  as  to  the  existence 
of  the  disease  in  the  neighbourhood. 

The  presence  of  the  catarrhal  phenomena  will  enable  us  to  exclude 
scarlatina  should  the  combination  of  sore  throat  and  high  temj)erature  have 
led  us  to  suspect  the  onset  of  that  disorder.  If  laryngitis  with  stridor  and 
spasm  be  an  early  symptom,  the  persistence  of  high  fever  after  the  spas- 
modic attack  is  at  an  end  will  suggest  that  these  manifestations  may  be 
symptomatic  of  some  latent  febrile  disorder,  and  we  shall  remember  that 
measles  is  sometimes  ushered  in  by  laryngeal  troubles. 

When  the  rash  appears  we  shall  be  less  liable  to  fall  into  error.  The 
crescentic,  slightly  elevated  patches  with  the  skin  between  them  of  a 
healthy  tint,  combined  with  coryza  and  cough,  are  very  characteristic.  If 
the  erujDtion  come  out  first  as  hardish  isolated  papules,  smaU-pox  may  be 
suspected,  and  indeed  this  is  a  mistake  which  is  often  made.  But  the 
papules  have  not  the  hard  shotty  feeling  peculiar  to  the  variolous  erup- 
tion ;  there  is  no  history  of  pain  in  the  back  ;  and  vomiting,  if  it  have  oc- 
curred, is  much  less  severe  than  the  vomiting  of  the  pre-eruptive  period  of 
small-pox.  Moreover,  in  variola  the  temperature  falls  notably  on  the  ap- 
pearance of  the  rash  ;  while  in  measles,  if  any  change  occur  at  all  in  the 
fever,  it  is  in  the  opposite  direction  ;  and  the  catarrhal  symptoms  become 
aggravated.  Doubt  is  only  permissible  at  the  very  beginning  of  the  erup- 
tive stage  ;  for  on  the  second  day  the  rash  of  small-pox  has  completely 
changed  its  character  on  the  face  of  the  patient,  the  papules  having  become 
converted  into  vesicles. 

The  rash  of  roseola  may  bear  a  close  resemblance  to  that  of  measles, 
but  in  the  former  complaint  there  is  no  catarrh,  and  the  temperature  is 
normal  or  only  slightly  elevated.  Between  epidemic  roseola  (or  rotheln) 
and  measles  the  difficulty  of  distinguishing  is  often  very  great.  This  sub- 
ject is  referred  to  in  the  chapter  treating  of  the  former  disorder  (see 
page  30).  I  have  also  known  the  early  signs  on  the  skin  of  an  acute  gen- 
eral eczema  to  present  the  closest  possible  resemblance  to  measles.  But 
an  exanthem  should  never  be  judged  of  by  the  rash  alone.  In  every  case 
we  should  search  for  confirmatory  symptoms,  and  inquire  as  to  the  tem- 
perature and  the  initiatory  phenomena  of  the  illness.  In  measles  we  ex- 
amine the  eyes  for  injection,  the  throat  for  redness,  and  ask  about  cough, 
hoarseness,  and  catarrhal  symptoms  generally.  If  these  are  completely  ab- 
sent, and  the  temperature  be  below  100°,  it  is  very  unlikely  that  the  disease 
is  measles,  however  typical  the  rash  may  appear. 

The  stains  left  on  the  skin  as  the  rubeolous  eruption  dies  away  have 
been  compared  to  the  mottling  of  syphilitic  roseola,  but  the  history  and 
course  of  the  illness  are  so  difierent  in  the  two  cases  that  hesitation  is  im- 
possible. 

Prognosis. — The  percentage  of  mortality  in  measles  is  small.  Still,  it 
is  much  higher  in  some  epidemics  than  it  is  in  others  ;  and,  therefore,  in 
estimating  the  chances  of  a  patient's  recovery  we  must  take  into  account 
the  character  of  the  epidemic.  Another  consideration  is  the  previous 
state  of  health,  especially  the  constitutional  tendencies  of  the  child. 
Unless  the  case  be  one  of  malignant  measles,  or  the  child  have  been  pre- 
viously in  a  state  of  great  weakness,  there  is  every  hope  of  preserving- 
life  if  ordinary  care  be  exercised  in  nursing  the  patient  through  his  ill- 
ness. But  it  is  less  easy  to  avert  injury  to  the  health  from  the  dangerous 
sequelae  of  the  disease.  In  spite  of  all  we  can  do,  a  child  of  strong  scrof- 
ulous predisposition  may  be  left  greatly  the  worse  for  the  attack  ;  and  if 
his  lungs  be  already  the  seat  of  caseous  consolidation,  it  will  be  difficult 


28  DISEASE  IX  childee:n". 

indeed  to  prevent  his  plitidsical  tendencies  from  receiving  a  distinct 
impulse. 

In  children  under  two  or  three  years  of  age  bronchitis  is  a  common 
comphcation.  Here  the  child's  previous  health  is  a  point  of  very  great 
importance.  One  danger  in  these  cases  is  the  occurrence  of  collapse  of 
the  lung,  and  this  is  predisposed  to  by  the  presence  of  rickets,  or  by  gen- 
eral weakness  of  the  patient.  If  the  child  be  the  subject  of  marked  rickets, 
and  bronchitis  supers'ene,  his  chances  of  recovery  are  small.  Another 
danger  is  the  tendency  of  the  bronchial  inflammation  to  spread  into  the 
finer  bronchial  tubes  and  au'-vesicles,  and  give  rise  to  catai-rhal  pneumonia. 
The  occurrence  of  this  accident  greatly  increases  the  gravity  of  the  case  ; 
but  if  the  child  be  a  healthy  subject,  and  the  epidemic  be  a  mild  one,  the 
chances  are  in  favour  of  recovery,  for  in  measles  catarrhal  pneumonia  tends 
to  run  a  subacute  coui'se.  If,  however,  the  child  be  weakly,  or  the  case 
occur  in  the  midst  of  an  ej)idemic  of  unusual  severity,  we  should  speak 
very  g-uardedly  of  his  hojDes  of  escape. 

Treatment. — In  the  early  stage  of  measles  the  treatment  is  that  of  a 
severe  cold  on  the  chest.  The  child  must  be  kept  in  bed,  put  upon  a  diet 
of  milk  and  broth  with  dry  toast,  and  take  for  medicine  a  sahne  with  some 
uiistimulating  expectorants.  "WTiile  the  cough  is  hard  and  the  chest  tight, 
the  stimulating  expectorants,  such  as  ammonia,  squill,  and  senega,  should 
on  no  account  be  made  use  of,  as  they  increase  the  tightness  of  the  chest 
and  make  secretion  more  difi&cult  than  before.  If  vomiting  be  distressing, 
an  emetic  may  be  given  to  reheve  the  stomach  of  unhealthy  secretions. 
Mustard,  or  sulphate  of  coj)per  (gr.  ^  to  gT.  ^  every  ten  minutes),  is  to  be 
preferred  for  this  puipose,  as  ipecacuanha  has  a  very  irritating  effect  upon 
the  bowels  of  some  children.  If  there  be  diarrhoea,  a  small  dose  of  castor- 
oil  or  of  rhubarb  and  soda  will  be  of  service  at  the  beginning  of  the  attack  ; 
but  the  aperient  should  not  be  repeated,  for  in  measles  the  bowels  are  veiy 
susceptible  to  the  action  of  piu'gatives.  If  the  diarrhoea  continue,  a  mix- 
ture of  aromatic  chalk  powder  and  rhubarb,  five  grains  of  each,  may  be 
given  to  a  child  three  years  of  age  every  night  for  thi'ee  nights  ;  or  he  may 
take  oxide  of  zinc  with  glycerine  (two  grains  thi'ee  times  a  day),  and  either 
of  these  will  usually  arrest  the  purghig.  Still  a  moderate  looseness  should 
not  be  interfered  with.  It  is  better  not  to  employ  astringent  remedies  un- 
less the  stools  are  veiy  watery,  and  threaten  by  their  number  to  reduce 
the  patient's  strength. 

The  general  management  of  the  child  must  be  conducted  according  to 
the  niles  ah-eady  laid  down  for  the  niu-sing  of  febrile  complaints  (see  Inti'o- 
duction).  In  cases  of  measles  special  care  should  be  taken  to  avoid  draughts 
while  insuring  free  ventilation  of  the  room.  A  strong  light  hurts  the 
reddened  eyes,  so  care  should  be  taken  to  keep  the  room  in  a  half  light, 
without  making  it  actually  dark.  Due  attention  must  be  paid  to  cleanli- 
ness. It  is  not  necessary  in  cases  of  measles  to  keep  the  child  du'ty.  The 
skin  should  be  cleansed  every  morning  ;  using  tepid  water,  and  being  care- 
ful to  wash  and  dry  sejDarately  each  part  of  the  body,  so  that  the  whole 
surface  may  not  be  exposed  at  one  time.  The  patient  may  be  allowed  to 
take  fluid  often,  but  he  must  be  prevented  from  drinking  large  quantities 
at  once.  The  best  drink  is  pure  filtered  water,  and  if  a  small  cup  or  glass 
be  used,  the  child  will  be  satisfied  if  allowed  to  drain  it  to  the  bottom. 

The  condition  of  the  throat  usually  requires  httle  treatment.  A  strip 
of  lint  wi'ung  out  of  cold  water  may  be  applied  closely  round  the  neck,  and 
be  covered  with  oiled  silk  and  flannel.  This  can  be  re-wetted  as  often  as 
■is  necessary.     The   same  apphcation  is  useful  if  there  be  much  inflam- 


MEASLES — TREATMENT.  29 

mation  of  the  larynx ;  and  if  spasm  occur  with  striclulous  breathing,  the 
throat  may  be  fomented  by  applying  below  the  chin  a  sponge  dipped  in 
water — hot,  but  not  hot  enough  to  scald. 

A  single  convulsion  does  not  require  treatment;  but  if  the  fits  are 
repeated,  the  child  should  be  placed  for  a  few  minutes  in  a  warm  bath  and 
then  be  returned  to  his  bed.  A  hot  bath  is  useful  if  capillary  bronchitis 
or  catarrhal  pneumonia  occur  early,  and  interfere  with  the  development  of 
the  rash.  If  they  occur  later  during  the  subsidence  of  the  eruption,  the 
child's  back  should  be  dry-cupped,  or  be  covered  with  a  large  poultice 
made  of  one  part  of  mustard  to  five  or  six  parts  of  linseed  meal.  This  can 
be  kept  in  position  for  eight  or  ten  hours,  and  afterwards  the  front  of  the 
chest  can  be  poulticed  in  the  same  way  In  cases  where  the  danger  is 
great,  the  dry  cups  are  to  be  preferred  to  the  more  slowly  acting  poultice  ; 
and  I  believe  life  may  be  often  saved  by  the  timely  use  of  this  energetic 
measiu-e. 

Stimulants  are  not  required  in  ordinary  cases  of  measles,  but  when  the 
patient  is  of  weakly  habit  of  body  or  of  distinct  scrofulous  type,  or  when 
he  is  suffering  from  an  unusually  severe  attack  of  the  disease,  it  may  be 
necessary  to  support  the  strength  by  alcohol.  The  brandy-and-egg  mix- 
ture of  the  British  Pharmacopoeia  is  very  useful  for  this  purpose,  and  may 
be  given  in  such  doses  as  the  child's  age  and  condition  require.  Children 
— even  very  young  children — who  are  weakly  or  prostrated  by  illness  re- 
spond well  to  stimulants,  and  can  take  them  in  considerable  quantities  with 
great  advantage.  I  have  often  seen  an  infant  of  eight  or  nine  months  of 
age  greatly  benefited  by  a  teaspoonful  of  brandy-and-egg  mixture  given 
every  hour  Of  this  quantity  a  third  part  is  pure  brandy.  If  without  the 
occurrence  of  any  severe  complication  the  patient  seems  to  be  getting  into 
a  typhoid  state,  with  dry  tongue  and  small  rapid  pulse,  stimulants  are 
urgently  needed.  Also,  the  presence  of  bronchitis  or  pneumonia  will 
demand  a  recourse  to  the  same  remedy,  or  the  child  may  sink  and  die 
with  startling  suddenness. 

Food  must  also  be  given  with  care  and  judgment,  taking  pains  not  to 
overload  the  stomach,  but  to  proportion  duly  the  nourishment,  both  in 
quantity  and  quality,  to  the  age  and  strength  of  the  child.  In  all  cases  of 
weakness  the  milk  should  be  diluted  with  half  or  a  third  part  of  barley 
watei',  so  as  to  insure  a  proper  division  of  the  curd.  In  addition,  it  may 
be  guarded  by  .fifteen  or  twenty  drops  of  the  saccharated  solution  of  lime 
to  prevent  its  turning  acid  upon  the  stomach.  This  must  be  given  in 
small  quantities  at  regTxlar  intervals.  Strong  beef-tea,  or  beef-essence 
made  in  the  house,  is  also  very  useful  when  the  strength  is  failing,  but  it 
must  be  given  in  very  small  doses  at  sufficient  intervals.  Brandy  can  be 
added  if  necessary. 

When  the  rash  begins  to  fade  and  the  temperature  falls,  the  child,  if 
old  enough,  may  take  pounded  meat,  the  yolk  of  an  egg  lightly  boiled,  and 
a  little  hght  pudding. 

The  chronic  sequelae  must  be  treated  according  to  the  jniles  laid  down 
in  such  cases,  and  the  reader  is  referred  to  the  chapters  treating  of  these 
subjects.  It  may  only  be  added  that  quinine  is  invariably  required  at  the 
end  of  an  attack  of  measles ;  and  bracing  sea-au*  is  very  beneficial  in  has- 
tening the  return  of  health  and  strength.  This  is  of  especial  importance 
in  the  case  of  scrofulous  children,  who  will  also  requu-e  cod-liver  oil  as 
soon  as  their  stomachs  can  bear  it. 


CHAPTER  11. 

EPIDEMIC  EOSEOLA. 

EpiDEivnc  roseola,  often  called  rotheln  or  German  measles,  is  a  mild  infec- 
tious complaint  which  bears  so  close  a  resemblance  to  measles  that  it  is  in 
all  probabihty  frequently  confounded  with  it.  The  two  diseases  are,  how- 
ever, not  the  same,  for  rotheln  does  not  protect  against  measles,  and  is 
itself  often  seen  to  occur  in  a  child  who  has  been  lately  the  subject  of  that 
disorder.  The  complaint  is  almost  always  a  mild  one,  and  has  no  compli- 
cations or  sequelae. 

Symi^toms. — -The  stage  of  incubation  is  said  to  last  a  week.  "When  the 
disease  begins,  the  child  is  seen  to  lie  about  and  to  look  poorly.  He  is 
slightly  feverish  and,  if  old  enough,  complains  of  headache.  With  this 
there  are  the  usual  accompaniments  of  thirst  and  want  of  appetite ;  and 
sometimes  a  pain  in  the  back  has  been  complained  of — violent  in  character 
like  the  back-ache  of  small-pox.  The  pre-eruptive  stage  often  lasts  only  a 
few  hours,  or,  indeed,  may  be  even  absent.  Perhaps  its  average  duration 
may  be  taken  at  twenty-four  hours.  The  eruption  then  comes  out  on  the 
cheeks,  and  sides  of  the  nose,  as  dusky-red  slightly  elevated  papules,  the 
colour  of  which  disappears  on  pressure.  The  wrists  and  ankles  are  attacked 
almost  as  early  as  the  face ;  and  from  these  points  the  rash  quickly  spreads 
to  the  rest  of  the  body  and  limbs.  On  the  cheeks  the  rash  is  more 
papular  than  elsewhere.  It  differs  from  the  eruption  of  measles  in  that 
the  spots  do  not  group  themselves  in  crescentic  patches  ;  but  resembles  it 
in  the  tendency  of  the  rash  to  become  confluent  in  places.  Thus  a  large 
patch  of  uniform  redness  is  often  seen  on  the  cheeks  ;  and  sometimes  we 
find  the  same  confluence  of  rash  on  the  wrists  and  forearms,  the  legs  and 
the  ankles.  The  eruption  is  attended  with  a  good  deal  of  irritation,  and 
when  it  subsides,  is  followed  by  a  sHght  fine  desquamation. 

The  general  symptoms  during  this  stage  are  trifling.  The  fever  may 
persist  during  the  first  day  or  two,  but  often  subsides  soon  after  the  ap- 
pearance of  the  rash.  The  conjunctivae  may  be  injected,  but  there  is  seldom 
coryza  ;  and  if  cough  be  present,  it  is  insignificant.  One  almost  constant 
symptom  is  sore  throat.  This  generally  comes  on  with  the  rash,  and,  on 
inspection,  the  fauces  are  found  to  be  the  seat  of  diffused  redness  ;  and 
the  tonsils  may  be  inflamed  and  swollen.  The  soreness  subsides  in  a  day 
or  two,  but  after  a  short  interval  is  apt  to  return.  The  secondary  sore 
throat  ^is  a  characteristic  symptom  of  rotheln.  It  occurs  between  the 
third  and  seventh  day — usually,  according  to  Dr.  Tonge-Smith,  on  the 
fourth  or  fifth — and  is  accompanied  by  great  joain  and  much  swelling.  In 
the  severer  cases  the  voice  is  altered,  articulation  and  deglutition  are  dis- 
tressing, and  there  is  much  secretion  of  sticky  mucus.  The  temperature  at 
this  time  may  reach  103°  or  104°;  still,  even  when  the  throat  symptoms  are 
worst  there  is  no  prostration  or  even  any  feeling  of  general  illness.  Some- 
times '  the  glands  of  the  neck  are  enlarged  and  tender ,  and  in  some  epi- 


EPIDEMIC   ROSEOLA — DIAGNOSIS— TREATMENT.  31 

demies  the  post-cervical  glands  have  been  noticed  to  be  swollen.  The 
axillary,  ingmnal  glands,  etc.,  may  be  also  affected.  The  diu-ation  of  the 
eruptive  stage  is  three  or  four  days. 

An  attack  of  rotheha  is  then,  as  a  rule,  a  very  insignificant  matter.  The 
difficulty  is  to  distinguish  it  from  measles,  which  it  so  much  resembles,  The 
two  chief  points  of  distinction  are  the  shorter  period  of  the  eruptive  stage 
in  rotheln,  and  the  non-crescentic  arrangement  of  the  rash.  The  milder 
character  of  the  catarrh  will  hardly  serve  as  a  distinguishing  mark,  for 
sometimes  in  measles  the  cough  and  coryza  cause  httle  inconvenience  to 
the  patient  Another  point  is  the  lower  temperature.  Sometimes  in  ro- 
theln there  seems  to  be  scarcely  any  fever  at  all ;  and  when  present,  the 
pyrexia  generally  subsides  on  the  second  day.  In  spite  of  these  points  of 
contrast  between  the  two  complaints,  we  must  often  hesitate  to  express  a 
positive  opinion  upon  a  particular  case.  The  absence  of  any  increase  of 
fever  when  the  eruption  comes  out  may  afford  a  suspicion  that  the  case  is 
not  one  of  true  measles,  but  we  can  seldom  speak  with  certainty  upon  the 
first  day  of  the  rash.  On  the  second  or  third  day,  however,  if  we  find  the 
general  symptoms  still  retain  their  trifling  character,  and  if  the  fever  sub- 
sides before  the  rash  has  begun  to  fade,  we  may  conclude  the  case  to  be 
one  of  rotheln.  In  doubtful  cases  the  more  or  less  general  glandular  en- 
largement, especially  the  swelling  of  the  cervical  and  suboccipital  glands, 
is  a  very  susj)icious  symptom  ;  and  the  occurrence  of  secondary  sore  throat 
with  no  actual  sense  of  illness  is  very  suggestive  of  rotheln. 

The  disorder  has  been  described  as  a  mild  one,  but  it  is  right  to  say 
that  some  authorities  hold  that  it  may  assume  a  much  more  severe  charac- 
ter. Dr.  Cheadle,  from  careful  observation  of  two  epidemics,  which  pre- 
sented aU  the  characters  of  measles  and  occurred  in  succession  in  the 
same  district  within  the  same  year,  concluded  that  the  second  of  these  epi- 
demics was  rotheln  although  the  symptoms  were  severe,  and  the  laryngeal 
phenomena  especially  well  marked.  He  founded  this  opinion  upon  the 
shorter  period  of  incubation  during  the  second  epidemic,  and  upon  the 
fact  that  out  of  thirty  cases  in  which  absolutely  trustworthy  histories 
could  be  obtained,  twenty-two  had  had  measles  before,  and  ten  of  these 
under  his  own  immediate  observation  within  the  year.  Still,  we  may  re- 
member with  regard  to  this  latter  point  that  measles,  although  as  a  rule  it 
protects  the  subject  for  the  future  against  a  similar  attack,  is  perhaps  of 
all  the  contagious  fevers  the  one  most  liable  to  recur.  A  second  or  even 
a  third  attack  in  the  same  individual  is  far  from  uncommon,  and  sometimes 
the  interval  between  two  such  attacks  is  curiously  short. 

Treatment— The  patient  must  be  confined  to  one  room  while  the  fever 
lasts,  and  care  must  be  taken  that  he  is  not  overfed.  No  medicine  is 
required. 


CHAPTER  III. 

SCAELET   FEVER. 

ScAELET  fever  (or  scarlatina)  is,  like  measles,  one  of  the  commoner  in- 
fectious fevers  of  cliildliood.  It  usually  occm-s  in  epidemics  wliich  vary 
greatly  in  severitj^  One  attack,  in  the  large  majority  of  cases,  protects 
against  a  second,  for  it  is  a  disease  which  very  rarely  occurs  twice  in  the 
same  person.  A  second  attack  may,  however,  occur.  Some  time  ago  I 
saw  a  httle  girl,  aged  seven  years,  who  had  a  significant  histoiy  of  fever 
followed  by  desquamation  and  dropsy,  which  had  attacked  her  when  she 
was  in  perfect  health  two  years  before.  The  child  was  a  patient  in  the 
East  London  Childi-en's  Hospital,  suffering  from  general  amyloid  disease 
dependent  upon  spinal  caries  which  had  followed  the  illness  refen-ed  to. 
While  she  was  in  the  hospital  the  girl  again  contracted  scarlatina,  and  was 
sent  away  to  the  Fever  Hospital,  where  she  died. 

Sometimes  the  disease  appears  in  an  abortive  form  in  persons  who  are 
abeady  protected  by  a  previous  attack.  In  every  epidemic  of  scarlatina  it 
is  common  to  find  cases  of  anomalous  sore  throat  occm-ring  in  protected 
persons  exposed  to  the  infection.  Such  persons  may  communicate  the 
perfect  disease  to  others  who  are  not  protected. 

Causation. — The  fever  is  of  a  highly  infectious  nature,  and  is  readily 
communicable  from  one  individual  to  another.  Sporadic  cases  are  some- 
times met  with,  but  the  illness  generally  occurs  in  epidemics.  The  infec- 
tious principle  is  probably  not  at  all  volatile,  for  articles  of  clothing,  flan- 
nel, etc.,  have  been  kno^^ni  to  retain  their  poisonous  projDerties  for  long 
periods  of  time.  It  is  a  debated  question  whether  the  disease  ever  has  a 
spontaneous  origin.  Some  authorities  hold  that  it  may  be  generated  de 
novo  by  cesspools  and  ill- ventilated  dizains.  Different  epidemics  have  dif- 
ferent degrees  of  severity  ;  but  apart  fi'om  the  special  type  of  fever  preva- 
lent, the  intensity  of  the  disease  is  dependent  more  uj)on  the  constitu- 
tional state  and  sanitary  surroundings  of  the  recipient  than  uj)on  the 
severity  of  the  disease  in  the  person  from  whom  the  infection  is  conveyed. 
Scrofulous  children,  and  those  who  are  ill  cared  for,  or  are  exposed  for 
long  periods  to  an  impm^e  atmosphere,  are  likely  to  take  the  disease 
badly. 

During  the  fii-st  few  days  of  the  illness  the  patient  is  less  dangerous  as 
a  source  of  infection  than  he  afterwards  becomes.  The  time  of  desquama- 
tion is  probably  the  period  at  which  the  complaint  is  most  likely  to  be  car- 
ried away,  for  the  particles  of  epithelium  thrown  off  must  be  highly  con- 
tagious, and  the  patient's  power  of  communicating  the  disease  does  not 
cease  vmtil  the  peeling  of  the  skin  is  at  an  end. 

Scarlatina  is  seen  less  frequently  than  measles  duiing  the  first  twelve 
months  of  life  ;  but  between  the  fiorst  and  second  years  the  disease  is  a 
common  one,  and,  according  to  the  researches  of  Dr.  Murchison,  64  per 
cent,  of  the  cases  occur  before  the  completion  of  the  fifth  year.     After  the 


SCAELET  FEVEK — MOEBID   ANATOMY —SYMPTOMS.  33 

tenth  year  the  disease  again  becomes  less  frequent,  although  it  may  occur 
during  adult  life  or  even  in  extreme  old  age. 

Morhld  Anatoviy. — After  death  from  scarlatina  we  usually  find  evi- 
dence of  the  special  complications  which  have  determined  the  fatal  issue. 
In  addition  the  blood  coagulates  imperfectly,  as  a  rule,  although  pale 
fibrinous  clots  may  be  found  in  the  right  ventricle. 

The  parts  especially  prone  to  suffer  are  the  gastro-intestinal  mucous 
membrane  and  the  glandular  system.  In  fatal  cases  inflammatory  swell- 
ing is  found  in  the  lymphatic  glands  of  the  neck  ;  also  in  the  follicles  at 
the  base  of  the  tongue,  and  in  those  of  the  pharynx,  tonsils,  and  larynx. 
In  the  intestine  the  sohtary  glands  and  those  of  Peyer's  patches  are  often 
enlarged,  reddened,  and  softened.  There  may  be  also  enlargement  and 
softening  of  the  spleen,  Hver  and  pancreas.  In  all  these  organs,  according 
to  Dr.  Klein,  there  are  changes  in  the  small  blood-vessels,  A  hyaline 
thickening  is  noticed  in  the  arterioles,  with  a  proliferation  of  the  cells  of 
the  endothelium  and  of  the  nuclei  in  the  muscular  coat,  together  with  an 
accumulation  of  lymphoid  cells  in  the  tissues  around.  In  the  gastro- 
intestinal mucous  membrane  there  is  hypersemia  of  the  subepithelial 
layers,  and  great  proliferation  of  cells  which  distend  and  obstruct  the 
gastric  tubules.  Sometimes  casts  of  these  tubules  may  be  detected  in  the 
matters  ejected  from  the  stomach. 

The  cutaneous  affection  is  not  a  mere  hypersemia.  It  is  also  an  exuda- 
tion into  the  rete  mucosum.  The  cells  m  this  situation  are  proliferated 
and  swollen,  and  the  sweat-glands  may  be  stuffed  and  distended  by  their 
increased  cellular  contents.  Serous  eilusions  with  migration  of  leucocytes 
may  also  occur.  The  lymphatic  glands,  especially  those  of  the  neck,  are 
enlarged  ;  the  lymphoid  cells  disappear,  and  in  places  large  giant  cells  be- 
come developed  containing  many  nuclei. 

The  kidney  presents  the  characters  of  acute  Bright's  disease.  The 
whole  organ  is  congested,  and  important  changes  are  noticed  in  the  glom- 
eruli, the  small  arteries,  and  the  convoluted  tubes.  According  to  Dr.  Klein, 
these  chan^^'es  take  place  very  early,  so  that  in  the  first  week  of  the  disease 
proliferation  of  the  nuclei  in  the  Malpighian  tufts  and  in  the  muscular 
coat  of  the  arteries  can  be  detected,  as  well  as  hyaline  degeneration  of  the 
intima.  At  the  same  time  there  is  hyaline  thickening  of  the  walls  of  the 
Malpighian  capillaries,  and  cloudy  swelhng  of  the  epithehum  in  some  of 
the  convoluted  tubes.  At  a  later  stage  the  cloudiness  and  swelling  of  the 
tubal  epithelium  increases,  and  fatty  degeneration  takes  place  ;  infiltra- 
tion of  lymphoid  cells  occurs  into  the  interstitial  tissue  around  the  tubules  ;, 
and  the  tubules  themselves  are  filled  with  hyaline  casts. 

In  cases  of  uraemia  the  blood  is  sometimes  found  to  contain  an  enor- 
mous excess  of  urea.  In  a  case  reported  by  M.  D'Espine  of  Geneva,  in. 
which  venesection  was  employed,  the  blood  was  found  to  contain  3.3  parts; 
of  urea  per  thousand,  or  about  twelve  times  the  normal  quantity.  The. 
potash  salts,  also,  were  increased  to  three  times  the  natural  proportion, 
and  of  this  two-thirds  was  contained  in  the  serum,  and  not,  as  in  healthy 
blood,  in  the  red  corpuscles.  From  the  experiments  of  Feltz  and  Ritter, 
and  others,  it  appears  probable  that  the  symptoms  of  ura3mic  poisoning  are 
due  not  to  the  retained  lu-ea,  but  to  the  excess  of  potash  salts  in  the  blood. 

Symptoms.  — ^ After  exposure  to  infection  a  period  of  incubation  pre- 
cedes the  actual  outbreak  of  the  fever.  This  stage  is  of  very  variable 
duration.  It  may  last  only  twenty-four  hours,  or  be  prolonged  to  a  week 
or  more.  Probably  six  days  may  be  taken  a,s  the  ordinary  duration  of  this 
period. 


34  DISEASE  IN   CHILDEEN. 

Dijfferent  cases  of  scarlatina  vary  so  mucli  in  severity  and  in  the  vio- 
lence of  special  symptoms  that  it  will  be  convenient  to  divide  the  disease 
into  two  chief  forms  :  The  common  mild  form  and  the  mahgnant  form. 
Afterwards  the  complications  and  sequelae  \vill  be  described. 

In  the  comimon  form  the  invasion  of  the  disease  is  abrupt.  It  begins 
with  a  chiU  ;  the  child  complains  of  sore  thi'oat,  and  generally  vomits. 
Sometimes  there  are  nervous  symptoms,  and  in  exceptional  cases  the 
disease  may  be  introduced  by  a  convulsion  or  a  state  resembling  coma. 
The  tongue  is  generally  furred  at  the  back,  red  at  the  tip  and  edges  ;  the 
appetite  is  lost,  and  there  is  thirst.  The  skin  is  hot,  and  the  pulse  rises  to 
130°,  140°,  or  even  higher.  The  rash  sometimes  appears  within  a  few  hours 
of  these  early  symptoms :  occasionally  it  is  itself  one  of  the  early  phe- 
nomena ;  and  again  in  rare  cases  it  may  be  delayed  for  three  or  foui-  days, 
or,  it  is  said,  even  for  a  week.  As  a  rule  it  is  noticed  within  twenty-four 
hours  of  the  beginning  of  the  disease.  The  temperature  rises  progres- 
sively through  the  invasion  stage  until  the  rash  appears.  The  pyi-exia  is 
not,  however,  excessive.  In  the  case  of  the  httle  gii'l,  before  referred  to, 
who  was  taken  with  scarlatina  while  in  the  hospital,  her  temperature  had 
always  been  normal,  but  one  evening  it  was  noticed  to  be  100.2°,  The 
next  morning  it  was  101.2°,  and  the  cliild  vomited  several  times.  Toward 
the  evening  the  rash  appeared,  and  the  merciuy  reached  103°.  In  another 
case — a  little  boy  aged  eight  months,  who  was  teething — the  temj^erature 
for  several  days  had  been  100°.  One  morning  it  rose  to  102.2°;  he 
vomited,  and  in  a  few  hours  the  rash  appeared.  To  the  hand,  perhajDS, 
the  skin  gives  the  imjDression  of  being  hotter  than  it  actually  is,  for  the 
heat  is  often  accompanied  by  a  pecuhar  dryness,  which  gives  a  burning 
character  to  it  like  that  of  j)neumonia.  Tested  by  the  thermometer,  the 
temperature  "will  be  rarely  found  to  exceed  105°. 

"With  the  appearance  of  the  rash  the  invasion  stage  comes  to  an  end 
and  the  eruptive  stage  begins.  The  rash  fii'st  appears  as  scarlet  points, 
not  elevated  above  the  surface.  These  are  closely  set,  and  their  borders, 
which  are  jDaler  than  the  centre,  unite  so  as  to  produce,  when  fiolly  devel- 
oped, the  appearance  of  a  uniform  pink  ground  dotted  thickly  over  with 
scarlet  points.  The  rash  rarely  aft'ects  the  face  to  the  same  degree  that 
it  does  the  rest  of  the  body,  and  differs  in  this  respect  from  the  eruption 
of  measles.  Usually  the  region  about  the  mouth  is  comparatively  free, 
and  contrasts  by  its  paleness  with  the  deej)  red  tint  of  neighbouring  parts. 
The  colour  of  the  rash  disappears  on  pressure  of  the  finger.  T\Tien  the 
eruption  is  confluent,  as  it  is  in  a  typical  case,  no  intervening  healthy  skin 
can  be  seen.  Often,  however,  the  eruption  is  not  confluent.  The  puncta 
are  then  more  or  less  isolated,  and  may  be  separated  by  spaces  in  which 
the  skin  has  the  normal  colour.  The  rash  may  be  confluent  in  some  places, 
not  in  others.  On  the  cheeks,  neck,  chest,  abdomen,  and  inner  aspect  of 
the  aiTQS  and  thighs,  coalescence  of  the  neighbouring  puncta  is  usually 
complete.  In  other  parts  the  spots  may  be  more  or  less  isolated.  Some- 
times the  eruption  is  everywhere  discrete.  The  puncta  are  then  usually 
larger  ;  and  if  at  the  same  time  the  temperature  is  only  shghtly  elevated 
and  the  sore  throat  insignificant,  great  doubt  may  be  entertained  as  to  the 
nature  of  the  disease  ;  especially  as  when  thus  discrete  the  spots  are  often 
a  httle  elevated.     These  cases  have  been  mistaken  for  measles. 

Again,  the  colour  of  the  rash  may  vary.  It  may  be  very  pale,  so  as  to 
be  only  discovered  by  careful  examination  ;  or  it  may  be  dusky  and  pur- 
j)le.  Often  it  is  more  pink  than  scarlet.  Sometimes  it  is  hmited  to  certain 
parts  of  the  body,  such  as  the  sides  of  the  neck,  the  chest,  or  abdomen, 


SCARLET   FEVER— SYMPTOMS.  35 

and  cannot  be  detected  upon  the  limbs.  It  is  usually  said  to  begin  about 
the  root  and  sides  of  the  neck  and  on  the  chest ;  but  if  so,  these  pax'ts 
precede  the  rest  of  the  body  by  a  very  short  interval,  and  the  rash  be- 
comes general  very  quickly.  It  is  at  its  height  on  the  third  or  fourth  day 
of  the  illness.  There  is  then  often  a  good  deal  of  irritation  of  the  skin, 
and  some  subcutaneous  oedema  is  present,  which  makes  the  fingers  stiff 
and  clumsy-looking.  The  rash  may  be  accomjDanied  by  miliaria  about  the 
neck  and  chest ;  the  skin  is  often  rough  from  enlargement  of  the  sub- 
cutaneous papillse  (cutis  anserina)  ;  and  petechise  are  not  unfrequently 
present.  These  small  hsemon-hagic  spots  do  not  necessarily  indicate  any 
special  severity  in  the  attack.  Sometimes  also  vesicles  or  even  papules 
may  be  noticed.  "When  the  eruption  is  at  its  height,  a  line  drawn  upon 
the  reddened  surface  by  the  finger-nail  remains  visible  as  a  white  streak 
for  about  a  minute.  This  sign  has  been  considered  to  be  jDathognomonic. 
The  rash  begins  to  fade  on  or  after  the  fifth  day  of  the  illness,  and  has 
usually  completely  disappeared  by  the  tenth. 

During  the  eruptive  stage  the  symptoms  of  the  invasion  period  increase 
in  intensity.  The  tongue  cleans  and  becomes  deep  red  with  swollen  pa- 
pillae, so  as  to  present  the  well-known  strawberry  appearance.  The  child 
is  very  thirsty,  but  in  the  milder  cases  has  a  fair  appetite.  Vomiting  is 
seldom  repeated  after  the  first  day  ;  but  in  excej)tional  cases  this  symptom 
is  an  obstinate  and  distressing  one,  adding  greatly  to  the  gravity  of  the 
case.  If  severe,  it  may  reduce  the  temperature.  The  soreness  of  throat 
usually  increases  during  the  eruptive  stage  ;  and  examination  of  the 
fauces  shows  a  bright  redness  of  the  soft  palate,  uvula,  tonsils,  pillars  of 
the  fauces,  and  often  of  the  back  of  the  pharynx.  Sometimes  these  parts 
are  also  swollen  from  oedema,  so  that  the  uvula  is  broad  and  the  tonsils 
nearly  meet  in  the  middle  line.  There  is  also  in  most  cases  excess  of  ton- 
sillitic  secretion,  and  yellow  pulpy  matter  may  be  seen  collected  at  the 
mouths  of  the  follicular  recf.;sses,  or  even  coating  the  surface  in  a  uniform 
layer.  If  the  matter  do  not  escape,  it  may  form  an  abscess  in  the  tonsil, 
as  in  common  quinsy.  In  the  more  severe  cases  the  tongue  loses  its  moist 
appearance  and  the  mucous  membrane  of  the  mouth,  and  throat  gener- 
ally, looks  dry  and  shining.  Unless  in  the  worst  cases,  ulceration  does  not 
occur  until  the  disease  is  subsiding.  Sometimes  at  an  early  period  the 
disease  is  complicated  with  diphtheria.  If  the  throat  affection  is  severe, 
there  is  much  pain  and  tenderness  in  swallowing  ;  the  voice  is  nasal  in 
quality  ;  and  the  glands  of  the  neck  become  enlarged  and  tendei*.  The 
inflammation  may  extend  from  them  into  the  connective  tissue  around,  and 
end  eventually  in  suppuration.  In  an  ordinary  case  the  throat  improves 
as  the  eruption  fades  ;  but  the  tonsils  and  the  lymphatic  glands  may  re- 
main enlarged,  although  painless,  for  some  time  after  the  inflammation  has 
subsided. 

The  degree  of  pyrexia  as  a  rule  is  moderate.  The  temperature  seldom 
rises  above  105°,  although  in  exceptional  cases  it  may  reach  a  higher  ele- 
vation. Unless  it  be  maintained  by  the  presence  of  a  febrile  complication, 
the  temperature  tends  to  subside  when  the  rash  begins  to  fade  ;  and  a 
crisis  then  usually  occurs,  the  heat  of  the  body  being  normal  for  twenty- 
four  hours.  Should  tliis  crisis  not  occur,  the  pyrexia  may  be  prolonged 
for  several  days.  Even  in  a  mild  uncomplicated  case  I  have  known  the  tem- 
perature to  remain  elevated  two  degrees  above  the  normal  level  for  twelve 
days.  As  long  as  the  fever  continues,  the  pulse  is  as  frequent  as  at  the 
beginning,  and  slackens  when  the  temperature  falls.  It  often  reaches  160, 
and  this  frequency  is  not  to  be  taken  as  a  sign  of  danger.     So,  too,  deli- 


36  DISEASE  IlSr   CHILBEEN. 

rium  may  be  present,  and  if  slight  and  occiu'ring  only  at  night,  is  not  of 
serious  import.  The  child  often  complains  of  headache  and  of  aching  pain 
about  the  limbs. 

The  urine  is  scanty  and  high  coloured.  It  may  contain  excess  of  bile  pig- 
ment, and  there  is  often  a  sediment  of  Hthates  or  of  free  uric  acid.  Ac- 
cording to  Dr.  Gee,  the  chlorides  are  sensibly  reduced  in  quantity,  and  the 
phosphoric  acid  undergoes  a  decided  reduction.  The  urea  is  not  neces- 
sarily increased. 

The  desquamative  stage  begins  a  few  days  after  the  rash  has  faded. 
The  exact  period  at  which  it  can  be  first  noticed  is  very  variable.  The 
first  sign  of  peeling  may  be  seen  while  the  skin  is  still  tinted  with  the  re- 
mains of  the  eruption  and  before  the  pja-exia  has  subsided  ;  or  it  may  be 
delayed  for  some  days  or  even  weeks  after  the  rash  has  disappeared.  It 
usually  occurs  early  in  proportion  to  the  intensity  of  the  eruption,  and  if 
miHaria  has  been  present,  is  often  early  and  profuse.  In  the  slighter  cases 
it  may  be  long  delayed,  and  Dr.  Page  states  that  after  a  mild  attack  he  has 
known  desquamation  to  be  postponed  for  five  weeks.  The  epithelium  at 
first  looks  dry  and  may  be  finely  wrinkled.  Then,  on  the  neck,  uj^per 
part  of  the  chest,  and  front  of  the  shoulders,  the  skin  begins  to  fall  in  fine 
bran-like  scales.  Over  those  parts  where  the  cuticle  is  thin  and  deli- 
cate the  desquamation  is  very  fine.  Where  the  skin  is  thicker  the  parti- 
cles thrown  off  are  larger,  and  in  some  places,  such  as  the  hands  and  feet, 
large  areas  of  epithelium  may  be  cast  off  unbroken.  On  close  inspection 
of  the  peeling  surface  the  cuticle  will  be  seen  to  be  raised  in  the  form  of 
an  empty  vesicle.  The  crown  of  this  elevation  falls,  leaving  a  minute  circle, 
which  gradually  extends  itself,  until  its  circumference  meets  other  circles 
widening  in  the  same  way.  If  the  crown  of  the  vesicle  does  not  break  off, 
the  separation  of  the  epithelium  may  go  on,  at  the  periphery  until,  by  the 
coalescence  of  neighbouring  centres  of  desquamation,  large  tracts  of  skin 
are  thrown  off. 

The  process  may  be  over  in  ten  days  or  a  fortnight,  or  may  be  pro- 
longed for  weeks.  It  often  lingers  long  about  the  fingers  and  toes.  A 
secondary  desquamation  is  even  said  to  occur  in  some  cases,  and  the  peel- 
ing undergoes  a  species  of  relapse.  Until  the  last  flake  of  epithelium  has 
been  cast  off  the  patient  cannot  be  said  to  be  completely  free  from  in- 
fection. 

In  this  stage  the  pulse  is  at  first  often  slower  than  natural,  and  may 
intermit.  The  temperature,  also,  after  the  cessation  of  the  pyrexia,  remains 
subnormal  for  some  days. 

In  malignant  scarlatina  the  severity  of  the  disease  is  shown  either  by 
violence  of  nervous  phenomena  which  prove  rapidly  fatal ;  or  by  the_  early 
ajDpearance  and  intensity  of  the  throat  affection,  which  causes  death  in  the 
first  or  second  week  of  the  illness. 

In  the  first  form  the  disease  from  the  beginning  may  show  the  utmost 
violence.  The  vomiting  is  repeated  and  distressing  ;  the  child  is  agitated 
and  delirious  or  comnilsed  ;  the  temperature  rises  to  107°  or  108°  ;  the 
breathing  is  quick  and  shallow  ;  the  pulse  is  rapid.  After  some  hours  or 
days,  according  to  the  violence  of  the  symptoms,  the  patient  sinks  into  a 
stupefied  condition  with  haggard,  dusky  face,  cold  extremities,  a  feeble, 
rapid  pulse,  and  a  moist  skin.  He  vomits  frequently  or  may  be  violently 
purged,  and  dies  comatose  or  in  convulsions.  In  the  worst  cases  the  pa- 
tient seems  literally  overwhelmed  by  the  intensity  of  the  fever  poison,  and 
dies  before  the  rash  appears  or  the  sore  throat  has  assumed  any  special 
prominence.     Thus,  a  child  may  be  found  a  few  hours  after  his  first  attack 


'SCARLET   FEVER — COMPLICATIONS   AND   SEQUELS.  37 

collapsed  or  unconscious,  vomiting  incessantly,  and  passing  frequent,  thin, 
watery  stools.  The  throat  presents  a  dusky  redness ;  the  pulse  is  very 
rapid  and  feeble  ;  and  the  thermometer  in  the  rectum  marks  102°  or  103". 
In  a  few  hours  the  temperature  rises  to  105°  or  106°  ;  convulsions  come 
on,  and  the  child  dies.  In  other  cases  he  lingers  longer,  and  may  appear  to 
rally  for  a  time ;  but  the  depression  continues,  the  stupor  retur-ns,  and 
death  occurs  by  the  end  of  the  week. 

When  the  disease  assumes  a  malignant  form  from  exaggeration  of  the 
throat  affection,  the  course  of  the  disease  for  the  first  few  days  presents 
nothing  abnormal ;  but  on  the  fifth  or  sixth  day  the  fauces  become  exces- 
sively tender,  and  deglutition  is  very  difficult  and  painful.  The  lymphatic 
glands  at  the  angle  of  the  jaw  and  the  connective  tissue  around  them  are 
inflamed  and  swollen.  On  examination  of  the  throat  the  mucous  mem- 
brane is  seen  to  be  of  a  deep  red  or  dark  purple  colour,  and  patches  of 
ashy  gray  exudation  matter  are  dotted  over  the  surface  of  the  soft  palate, 
uvula,  and  tonsils.  In  the  bad  cases  ulceration  takes  place  in  these  spots, 
and,  spreading,  causes  wide  destruction  of  tissue.  The  face  is  often  livid 
and  haggard  ;  the  pulse  is  quick,  feeble,  and  fluttering  ;  there  are  sordes 
on  the  teeth  and  lips  ;  the  tongue  is  dry  and  brown  ;  the  fetor  of  the  breath 
is  extreme  ;  and  an  offensive  purulent  discharge  escapes  from  the  nose.  At 
the  same  time  the  neck  swells  and  feels  brawny  to  the  touch ;  the  skin 
melts  away  in  places  ;  and  thin,  purulent  mattei',  with  shreds  and  lumps  of 
sloughy  connective  tissue,  are  discharged  through  the  openings.  The 
sloughing  of  the  subcutaneous  tissue  of  the  neck  is  often  accompanied 
by  other  serious  symptoms.  Haemorrhage  may  take  place  from  the  large 
vessels  ;  oedema  of  the  glottis  may  occur  ;  the  patient  may  fall  into  a  ty- 
phoid state  or  die  from  pyemia.  In  one  way  or  another  such  cases  usually 
terminate  fatally. 

When  the  throat  affection  assumes  a  malignant  form  the  prostration  is 
generally  marked,  and  the  patient  lies  in  a  drowsy  state,  although  he  seems 
intelligent  enough  when  roused.  The  temperature  is  not  excessively  eleva- 
ted, seldom  rising  above  103°  ;  but  the  pulse  is  very  rapid  and  feeble.  It 
is  important  to  know  that  the  swelling  of  the  cervical  glands  is  not  always 
in  proportion  to  the  severity  of  the  throat  complication,  and  furnishes  no 
ground  upon  which  to  establish  a  prognosis.  Deep-seated  sloughing  and 
fatal  hsemorrhage  may  occur  in  cases  where  the  external  glands  are  only 
moderately  enlarged.  If  the  throat  affection  is  severe  from  the  first,  the 
appearance  of  the  rash'  may  be  delayed  for  several  days  ;  and  it  may  come 
out  in  a  patchy  manner,  being  most  marked  in  parts  where  the  skin  is 
especially  thin  and  delicate,  as  in  the  folds  of  the  arm-pits  and  groins. 

Sometimes  we  find  the  above  two  forms  of  malignant  fever  combined. 
The  nervous  symptoms  are  in  excess,  and  there  is  also  serious  ulceration  of 
the  fauces  and  destruction  of  tissue.  Convulsions  occurring  from  any 
cause  during  the  eruptive  period  are  of  very  serious  import,  and  generally 
end  fatally  whether  the  throat  symptoms  are  mild  or  severe. 

Complications  and  Sequeke. — The  intercurrent  disorders  which  are  hable 
to  occur  dru'ing  or  after  an  attack  of  scarlet  fever  may  be  looked  upon  as 
complications  or  sequelse,  according  as  to  whether  or  not  the  disease  is 
considered  at  an  end  when  the  temperature  returns  to  a  normal  level. 
Most  of  them  arise  during  the  second  week  of  the  illness,  although  some 
may  occur  earher.  They  will  be  described  in  the  order  of  theu*  occur- 
rence. 

During  the  Jirst  iveek  the  fever  may  be  complicated  by  diphtheria,  diar- 
rhoea, and  coryza.     The  ulcerative  throat  affection,  which  by  many  wiiters 


38  DISEASE  m   CHILDEEN. 

is  considered  as  a  complication,  has  been  described  as  a  phase  of  the  malig- 
nant form  of  the  fever. 

Diphtheria  may  be  an  early  compHcation  of  scarlet  fever,  and  may  spread 
to  the  nose  and  larynx.  It  often  comes  on  during  the  first  week  of  the 
illness,  but  may  occur  later  and  at  a  time  when  the  patient  is  supposed  to 
be  rapidly  approaching  convalescence.     It  generally  proves  fatal. 

Coryza  of  a  mild  character  occurring  in  the  course  of  the  first  week  is 
not  a  symptom  of  unfavourable  omen ;  but  if  it  persist  into  the  second  week, 
it  becomes  more  serious.  In  such  cases  the  catarrh  may  spread  along  the 
Eustachian  tube  into  the  tympanum  and  set  up  otitis.  If  in  any  case  the 
nasal  discharge  becomes  fetid,  it  suggests  the  presence  of  diphtheria. 

DiaiThoea  is  sometimes  an  early  complication.  It  usually  ceases  after 
a  day  or  two,  but  may  prove  so  severe  as  to  endanger  the  Ufe  of  the  patient. 
According  to  Henoch  it  is  preceded  by  swelling  of  the  Pyerian  and  sohtary 
glands.  Sometimes  as  the  rash  fades  the  diarrhoea,  which  had  at  first 
ap]3eared  of  little  importance,  passes  into  a  true  entero-colitis.  The  tem- 
perature which  had  fallen  rises  again  ;  there  is  nausea  and  often  vomiting  ; 
the  belly  is  swollen  and  perhaps  tender  ;  and  the  child  complains  much 
of  abdominal  pain.  The  tongue,  dry  and  hot,  is  furred  on  the  dorsum,, 
red  at  the  tip  and  edges.  The  bowels  are  loose,  and  the  stools  contain 
much  food  partially  digested,  mixed  up  with  mucus  and  sometimes  wdth 
blood.  The  child  looks  excessively  iU  and  rapidly  loses  flesh.  He  maj 
die  from  the  acute  attack,  or  the  complication  may  pass  into  a  chronic 
stage. 

In  the  second  iveek  bronchitis  and  pneumonia,  rheumatism,  and  seroua 
inflammations  may  be  seen. 

Bronchitis  and  pneumonia,  which  are  common  in  measles,  are  compara- 
tively rare  complications  of  scarlatina.  It  is  much  more  frequent  to  find 
inflammations  of  the  serous  membranes,  especially  of  the  pleura  and  peri- 
cardium ;  and  these  are  often  associated  with  symptoms  indistinguishable 
from  those  of  rheumatism. 

Scarlatinous  rheumatism  may  occur  during  the  second  week  or  beginning 
of  the  third,  and  is  often  met  with  as  a  comphcation  or  sequel  of  the  fever. 
Whether  the  disease  is  to  be  looked  upon  as  a  time  rheumatism  quite 
independent  of  the  scarlatina,  or  as  an  arthritis  resulting  from  septicaemia, 
or  as  a  further  manifestation  of  the  scarlet  fever  poison  which  may  fasten 
upon  the  joints  as  it  may  fasten  upon  the  kidneys  or  the  throat,  is  still  a 
matter  of  discussion.  The  rheumatic  attack  certainly  foUows  the  ordinary 
course  of  that  disease  ;  it  frequently  affects  the  serous  membranes  in  and 
around  the  heart ;  and  the  joint  inflammation  subsides,  as  a  rule,  after  a. 
day  or  two,  although  in  exceptional  cases  it  may  end  in  suppuration.  This, 
may,  however,  occur  in  cases  where  there  is  no  suspicion  of  scarlet  fever. 
Endocarditis  is  as  common  as  pericarditis,  and  heart  disease  in  the  child 
often  dates  from  an  attack  of  scarlatina.  Pleui'isy  and  pericarditis  some- 
times come  on  in  the  third  week  instead  of  the  second,  and  may  occur  in 
cases  where  joint  pains  are  not  complained  of.  They  may  then  be  a  symp- 
tom of  Bright's  disease  ;  but  pericarditis  from  this  cause  is  not  very  common 
in  the  child  as  a  sequel  of  scarlet  fever.  If  pleurisy  occur  the  effusion  very 
rapidly  becomes  purulent. 

In  the  third  week  the  patient  is  especially  Uable  to  kidney  mischief. 
At  this  time,  too,  or  shortly  afterwards,  otitis  may  occur,  and  gangi-ene 
and  abscesses  may  make  theu"  aiDpearance. 

The  m-ine  should  be  examined  daily  throughout  the  iUness  for  albumen. 
This  may  be  found  at  any  time  from  the  second  to  the  twenty-first  day. 


SCAPwLET   FEVEE — ALBUMINOUS    NEPIIEITIS.  39 

It  is,  however,  in  the  course  of  the  third  week  that  it  is  especially  liable  to 
be  met  with. 

Albuminuria  does  not  bear  any  relation  to  severity  of  attack.  It  may 
be  present  in  mild  cases  and  absent  in  severe  ones.  By  itself  it  does  not 
indicate  serious  renal  mischief,  and  if  small  in  quantity  does  not  affect  the 
prognosis. 

If  the  albuminuria  is  due  to  anything  more  than  a  simple  congestion 
of  the  kidneys,  which  is  of  little  consequence,  the  urine  soon  shows  signs 
of  the  presence  of  nephritis.  Its  quantity  is  reduced  :  its  colour  is  smoky 
from  the  presence  of  blood,  or  even  deep  red  if  the  hsemorrhage  is  co- 
pious ;  boiling  throws  down  a  copious  precipitate  of  albumen  ;  and  renal 
epithehum,  blood-disks,  and  casts,  granular  and  epithelial,  are  discovered 
by  the  microscope.  At  the  same  time  or  shortly  afterwards  the  face  is 
pale  or  puffy-looking  ;  the  eyelids  are  stiff  and  swollen  ;  and  more  or  less 
oedema  is  noticed  about  the  legs  and  ankles. 

The  beginning  of  the  kidney  complication  is  generally  announced  by 
vomiting,  headache,  loss  of  appetite,  a  dry  skin,  a  paUid  complexion,  an  ir- 
regular pulse,  and  a  rise  in  the  temperature.  The  temperature  is  not  very 
high,  seldom  exceeding  101°;  and  the  vomiting  is  not  often  repeated,  al- 
though sometimes  it  becomes  a  distressing  symptom.  The  oedema  varies 
in  amount.  Sometimes  it  is  httle  more  than  a  puffiness  of  the  skin.  In  other 
cases  the  swelling  may  be  general  and  severe,  so  as  completely  to  alter  the 
natural  expression  of  the  face,  and  greatly  distend  the  limbs  and  lower 
part  of  the  back.  At  the  same  time  effusion  may  take  place  into  the  se- 
rous cavities,  the  lungs,  and  even  the  glottis.  If  these  effusions  are  rapid 
and  copious,  great  lividity  and  dyspnoea  may  ensue,  and  death  may  take 
place  with  starthng  rapidity.  The  most  violent  attacks  of  dyspna?a  may 
be  induced  by  interstitial  oedema  of  the  lungs.  The  patient  is  found 
gasping  for  breath,  with  a  haggard,  hvid  face.  His  eyes  are  staring  and 
congested,  his  lips  blue,  and  his  nails  piirple.  His  pulse  is  weak  and 
rapid  and  his  heart's  action  feeble  and  fluttering.  On  examination  of  the 
chest  few  physical  signs  are  to  be  discovered.  The  rhonchi  are  scanty  and 
scattered,  for  very  little  fluid,  if  any,  exudes  into  the  air-passages  and  al- 
veoli. 

In  a  certain  proportion  of  cases  ursemic  symptoms  may  occur.  The 
child  is,  perhaps,  violently  convulsed  several  times,  and  may  lapse  into  a 
state  of  coma  ;  or  he  may  be  seized  with  headache  of  a  very  distressing 
character.  Fortunately  these  symptoms  usually  pass  off  under  the  influ- 
ence of  judicious  treatment.  It  is  exceptional  for  a  child  to  die  of  scarla- 
tinous nephritis.  The  occurrence  of  the  renal  complication  appears  to  be 
dependent  in  a  great  measure  upon  the  character  of  the  epidemic  ;  for 
while  in  some  it  is  a  common  symptom,  in  others  it  is  almost  entirely  ab- 
sent. The  popular  impression  that  it  is  always  the  consequence  of  a  chill 
has  been  disproved  over  and  over  again.  There  is  no  doubt  that  if  albu- 
minous nephritis  be  present,  a  chill  may  hasten  the  occurrence  of  dropsy  ; 
but  that  slight  exposure,  such  as  occurs  during  convalescence  from  scarlet 
fever,  can  determine  the  occurrence  of  the  nephi-itis  is  now  very  generally 
disbelieved. 

In  the  earlier  stage  of  the  nephritis  the  amount  of  urine  is  diminished 
and  its  specific  gravity  is  raised.  After  a  time  the  secretion  becomes  more 
copious  and  at  the  same  time  its  density  falls.  Usually  the  pyrexia  sub- 
sides when  the  quantity  of  urine  increases.  Dropsy  is  not  an  invariable 
symptom.  It  may  be  completely  absent,  althoixgh  the  other  jDhenomena 
are  well  marked.     As  a  rule  the  nephritis  is  rapidly  recovered  from,  and 


40  DISEASE  IX   CHILDEEN. 

the  albuminuria  and  ureemic  symptoms  quickly  disappear  ;  but  some- 
times, although  improvement  takes  place  in  other  respects,  the  water  still 
continues  to  throw  down  a  dejDOsit  on  boUing ;  for  a  long  time  a  certain 
amount  of  albumen  may  be  present,  and  under  the  microscope  the  sediment 
may  continue  to  exhibit  casts  of  tubes.  In  exceptional  cases  a  permanent 
albuminuria  may  be  left.  In  other  instances,  and  these  are  probably  more 
common  than  is  usually  suiDposed,  the  urine  ceases  to  contain  albumen  and 
casts,  and,  indeed,  with  the  exception  of  a  low  specific  gravity,  may  pre- 
sent all  the  characters  of  health.  StiU  the  restoration  of  the  kidneys  is  not 
comj)lete,  and  slight  causes,  such  as  a  iDassing  chill,  may  deteimine  a  return 
of  all  the  acute  symptoms  which  have  been  described. 

Droj)sy  without  albuminuria  is  occasionally  met  with,  and  this  not  a 
mere  ausemic  dropsy.  In  some  of  these  cases  albuminuiia  has  been 
present,  but  has  disappeared.  In  others  there  has  been  no  precedent 
albuminuria. 

Oton-hoea  is  a  not  uncommon  compKcation  of  scarlatina.  The  discharge 
is  often  due  to  an  inflammation  of  the  external  meatus,  and  is  then,  if  at- 
tended to  quickly,  of  little  consequence.  In  many  cases,  however,  it  is  a 
result  of  extension  of  the  catarrh  from  the  pharynx  or  nasal  cavities  thi'ough 
the  Eustachian  tube  to  the  middle  ear.  It  is  then  a  more  serious  matter, 
for  the  tympanum  soon  becomes  distended  with  its  purulent  contents. 
Destruction  of  the  small  bones  of  the  tympanum  usually  follows,  and  the 
pus  bursting  thi-ough  the  tympanic  membrane  escapes  by  the  external 
canal.  The  most  serious  consequences  may  arise  from  this  complication, 
as  will  be  described  elsewhere  (see  Otitis,  and  its  consequences). 

Abscesses  may  occur  in  the  second  or  thiixl  week,  or  towards  the  close 
of  the  stage  of  desquamation.  These  collections  of  pus  often  delay  con- 
valescence, and  if  they  occur  in  the  neck  may  be  signs  of  serious  import. 
In  the  cervical  region  they  are  nearly  always  the  result  of  internal  ulcera- 
tion. In  every  case,  therefore,  a  careful  examination  of  the  thi-oat  should 
be  made,  and  active  measures  are  required  to  prevent  any  spreading  of  the 
destructive  process  in  the  pharjTix.  A  not  uncommon  seat  of  abscess  at 
this  period  is  the  submucous  tissue  at  the  back  of  the  pharynx.  This 
subject  is  elsewhere  considered  (see  Eetro-pharyngeal  Abscess). 

Gangrene  in  various  parts  vaaj  occui\  Cancrum  oris  occasionally  fol- 
lows scarlet  fever  ;  and  gangrene  of  the  vulva,  the  j)harynx,  the  skin  of  the 
abdomen,  and  that  over  a  suppurating  gland  may  also  be  met  with.  Some- 
times, as  may  happen  in  the  case  of  any  fever  of  a  low  type  which  causes 
rapid  reduction  of  the  strength,  scarlatina,  if  severe,  is  followed  by  hsemor- 
rhagic  piirpura,  with  bleeding  from  several  mucous  surfaces.  Even  death 
may  ensue  as  a  conseqiience  of  the  loss  of  blood.  Neiwous  sequelse  m,ay 
be  also  met  with.  Infantile  spinal  paralysis  has  been  known  to  occui- ;  and 
hemiplegia  from  plugging  of  the  middle  cerebral  artery  is  seen  in  rare  in- 
stances. 

In  addition  to  the  above  complications,  scarlatina  is  sometimes  confused 
by  the  presence  of  other  specific  fevers.  Diphtheria  has  been  ah-eady  men- 
tioned. Besides  this  disease,  measles  and  small-pox  have  been  severally 
known  to  attack  the  scarlatinous  patient,  and  run  their  course  at  the  same 
time  with  it.  Typhoid  fever  and  scarlatina  have  been  also  met  ^\ith  to- 
gether. 

There  is  a  form  of  scarlatina  which  has  been  called  latent.  In  this 
variety  the  symptoms  are  mild  and  ill-defined,  and  the  rash  pale  and  im- 
perfectly developed,  or  even  quite  absent.  Indeed,  the  sjTnptoms  gener- 
ally ar&  so  little  severe  that  the  existence  of  the  fever  is  often  not  suspected 


SCARLET   FEVEE— DIAGNOSIS.  41 

until  desquamation  begins.  It  is  tlien  remembered  that  the  child  had 
complained  of  a  passing  sore  throat,  and  had  seemed  languid  and  heavy  for 
a  day  or  two,  but  nothing  more.  In  these  mild  cases  the  after-course  of 
the  illness  is  not  always  in  harmony  with  its  beginning.  Indeed,  in  no 
case  of  scarlatina,  however  shght  the  early  symptoms  may  appear  to  be, 
can  we  venture  positively  to  predict  a  favourable  course  to  the  illness. 

It  was  long  doubted  if  the  form  of  scarlatina  which  occurs  sometimes 
after  surgical  operations  was  a  true  scarlatina.  The  cases  are  usually  of  an 
inoffensive  type  and  the  general  symptoms  trifling.  Still,  a  more  severe 
form  of  the  disease  is  occasionally  met  with.  The  rash  appears  a  few  days 
(two  or  three  in  most  cases)  after  the  operation,  and  may  be  almost  the  only 
symptom.  There  is  often,  however,  high  fever,  but  the  soreness  of  throat 
is  insignificant.  Occasionally  desquamation  is  absent.  The  healing  of 
the  wound  is  greatly  retarded  by  the  comphcation.  That  the  disease  is 
really  scarlatina  is  shown  by  the  fact  that  it  protects  the  patient  from  the 
fever  poison  in  after-life. 

Diagnosis. — In  a  typical  case  scarlet  fever  is  a  disease  which  can  scarcely 
be  mistaken.  The  initial  vomiting  and  sore  throat,  with  elevation  of  tem- 
perature and  rapid  pulse,  followed  on  the  second  day  by  a  uniform  pink 
rash  dotted  thickly  over  with  scarlet  puncta,  is  sufficiently  characteristic. 
Unfortunately,  many  cases  are  not  typical.  The  sore  throat  may  be  scarcely 
percej)tible ;  the  rash  may  be  pale,  discrete,  and  partial ;  and  the  tempera- 
ture on  the  morning  of  tbe  second  day  may  be  little  elevated  above  the  nor- 
mal level.  A  child  with  chronic  enlargement  of  the  tonsils,  who  is  subject  to 
attacks  of  sore  throat,  is  found  to  be  feverish,  to  have  some  pain  in  deglu- 
tition, and  to  present  a  pale,  ill-developed  discrete  rash  limited  to  the  neck, 
chest,  abdomen,  and  thighs.  In  such  a  case  it  is  allowable  to  feel  some 
uncertainty  as  to  the  nature  of  the  ailment.  The  appearance  of  the  throat 
is,  however,  here  of  importance.  The  redness  is  not  limited  to  the  tonsils, 
but  extends  over  the  soft  palate,  uvula,  arches  of  the  fauces,  and  often 
the  back  of  the  pharynx.  The  redness  is  uniform,  but  at  its  margin  on 
the  soft  palate  some  punctiform  redness  may  be  seen  ;  or  the  redness  may 
be  punctiform  in  character  on  the  soft  palate,  and  uniform  elsewhere.  Such 
a  throat,  accompanied  by  vomiting,  a  hot  skin,  a  quick  pulse,  and  a  white- 
coated  tongue,  is  very  suspicious  of  scarlet  fever.  Some  forms  of  erythema 
imitate  the  rash  of  scarlatina  very  closely  ;  and  if  there  is  a  history  of  a 
recent  unwonted  indulgence  in  diet,  the  iUness  may  be  easily  attributed  to 
this  cause.  If  such  a  rash  be  accompanied  by  a  normal  temperature,  scar- 
latina may  be  positively  excluded.  But  it  is  important  to  remember  that 
the  increase  of  bodily  heat  may  be  very  moderate.  I  have  known  the 
morning  temperature  on  the  second  day  to  be  only  99.5°,  or  one  degree 
above  the  normal  level,  although  the  disease  was  a  true  scarlatina,  which 
afterwards  became  better  developed.  A  pulse  of  140,  however  mild  the 
other  symptoms  may  be,  should  make  us  suspect  the  existence  of  the  fever 
very  strongly  ;  and  in  no  case  where  the  temperature  reaches  100°  or  over 
should  we  venture  positively  to  exclude  the  disease.  An  erythematous  rash 
is  seldom  so  widely  diffused  as  is  the  eruption  of  scarlatina  ;  and  in  particu- 
lar is  usually  absent  from  the  neck  and  limbs.  It  also  spreads  very  irregu- 
larly. In  all  cases  of  doubt  we  should  inquire  about  pains  and  stiffness  in 
the  articulations,  and  examine  the  joints,  especially  those  of  the  fiugers, 
for  signs  of  swelling.  We  should  also  feel  for  enlarged  glands  in  the  neck. 
Often  these  symptoms  are  present  early,  when  the  erui^tion  is  very  partial 
and  incomplete. 

When  the  rash  is  dark  colored,  discrete,  and  slightly  elevated,  it  may 


42  DISEASE  IN   CHILDREN. 

be  mistaken  for  measles ;  but  tbe  absence  of  sneezing  and  lacbrymation, 
and  the  presence  of  bright  red  injection  of  the  throat,  with  an  unusually- 
rapid  pulse,  should  furnish  a  sufficient  distinction. 

Roseola  may  be  mistaken  for  scarlatina,  but  the  rose  eruption  occurs  in 
larger  spots,  and  indeed  more  resembles  measles  than  the  disease  we  are 
considering.  Moreover,  in  roseola  there  is  little  or  no  fever  ;  no  swell- 
ing of  the  joints  ;  and  the  rapidity  of  the  pulse  is  normal  or  only  moderately 
increased. 

Scarlatina  may  be  closely  simulated  by  ague.  Dr.  Cheadle  has  described 
the  cases  of  two  children  in  whom  the  skin  dui-ing  the  hot  stage  was  covered 
with  a  bright  red  rash.  This  eruption,  combined  with  a  quick  pulse  and 
a  high  temperature,  was  very  suggestive  of  scarlatina,  and  might  easily 
have  been  mistaken  for  it.  The  distinguishing  points  are  referred  to  else- 
where (see  Ague). 

Sometimes  in  the  mild  anomalous  cases  of  the  disease  desquamation 
may  be  long  delayed,  and  the  absence  of  peeling  may  be  held  to  exclude 
scarlatina.  In  these  cases  we  are  directed  by  Su'  WiUiam  Jenner  to  examine 
the  skin  about  the  roots  of  the  finger-nails  for  signs  of  scahng,  as  it  may 
be  discovered  in  this  situation  as  early  as  a  week  or  ten  days  from  the 
cessation  of  the  illness. 

Scarlet  fever  is  hardly  likely  to  be  confounded  with  diphtheria,  for  the 
invasion  and  general  symptoms  of  the  two  diseases  are  very  different.  It 
is  important,  however,  not  to  overlook  the  possible  intercurrence  of  diph- 
theria as  a  comphcation  of  the  fever.  If  this  unfortunate  accident  happen 
early,  during  the  first  week,  there  is  usually  an  offensive  discharge  fi'om 
the  nostrils ;  the  voice  often  becomes  hoarse  ;  and  there  are  symptoms  of 
great  depression.  If  it  occur  at  a  later  period,  when  the  patient  seems 
approaching  convalescence,  the  fever  returns  ;  the  throat  becomes  again 
painful ;  the  glands  of  the  neck  enlarge  and  are  tender ;  there  is  a  dis- 
charge from  the  nose  ;  and  in  most  cases  the  larynx  becomes  quickly 
involved.  According  to  Trousseau,  scarlatina  avoids  the  larynx,  while 
diphtheria  has  a  well-known  tendency  to  attack  the  windpipe.  The  occur- 
rence of  hoarseness,  or  the  appearance  of  an  offensive  discharge  from  the 
nostrils,  in  any  case  of  scarlatina,  should  cause  us  at  once  to  make  fresh 
examination  of  the  throat ;  and  probably  the  appearance  in  the  fauces  of 
the  dirty- white  tough-looking  membrane  on  the  deep  red  swollen  surface 
will  at  once  prove  the  accuracy  of  our  anticipations. 

Prognosis. — Scarlatina  is  a  disease  as  to  the  course  of  which  it  is  unwise 
to  indi^ge  in  confident  predictions ;  for  an  attack  which  begins  mildly 
enough  may  end  in  a  very  different  manner.  Some  of  the  worst  cases  are 
those  which  begin  in  such  a  way.  Scrofulous  childi'en  are  bad  subjects  for 
scarlet  fever,  and  in  them  an  attack  of  apparently  mild  type  may  be  'fol- 
lowed by  a  distressing  series  of  comphcations.  Not  long  ago  I  attended 
a  young  girl  who  had  been  subject  for  years  to  scrofulous  disease  of  bone 
in  various  parts  of  the  body.  She  was  taken  with  scarlatina.  The  symp- 
toms were  sHght  at  first,  and  for  a  fortnight  there  was  no  cause  for  any- 
thing but  satisfaction  at  the  favourable  progress  of  the  illness.  In  the 
middle  of  the  third  week  all  this  was  changed.  The  patient  fii'st  began  to 
complain  of  rheumatic  pains.  She  was  then  attacked  in  rapid  succession 
by  albuminous  nephritis,  peri-  and  endo-carditis,  and  double  pleuiisy. 
Ulcerative  endocarditis  then  ensued,  which  led  to  cerebral  embohsm  with 
left  hemiplegia,  and  afterwards  to  renal  embolism,  with  return  of  the  albu- 
minuria and  casts  which  had  previously  disappeared.  The  girl  eventually 
died  suddenly  on  the  eighty-ninth  day,  apparently  from  clotting  in  the 


SCARLET   FEVER — PROGNOSIS — TREATMENT.  43 

pulmonary  artery.  In  cases  such  as  this  there  may  be  positively  no  indica- 
tion that  the  hitherto  benign  course  of  the  disease  is  to  change  so  seriously 
for  the  worse.  When,  however,  the  fever  has  assumed  a  severfe  form  in 
other  children  of  the  same  family,  we  must  always  be  prepared  for  some 
such  catastrophe  ;  and  until  the  disease  is  actually  at  an  end  we  cannot 
put  aside  our  apprehensions. 

Previous  ill  health  from  other  causes  than  scrofula  does  not  apparently 
modify  the  prognosis ;  nor  does  early  infancy  influence  unfavorably  the 
course  of  the  disease.  The  exact  character  the  fever  is  to  assume  appears 
to  depend  upon  the  type  of  the  epidemic  and  the  constitutional  peculiar- 
ities of  the  patient. 

The  malignant  forms  of  scarlet  fever  are  almost  invariably  fatal,  es- 
pecially those  in  which  the  nervous  symptoms  are  violent.  A  mild  noc- 
turnal delirium  is  not  of  unfavourable  omen  ;  and  slight  wandering  in  the 
daytime,  if  there  be  no  other  symptom  of  nervous  disturbance,  need  excite 
no  anxiety ;  but  if  the  delirium  is  active  and  persistent,  with  violent  agita- 
tion and  sleeplessness  passing  rapidly  into  stupor  and  prostration,  we  can 
have  little  hope  of  a  favourable  issue.  Convulsions  occurring  after  the  first 
day,  especially  if  repeated,  are  very  serious.  No  indication  is  to  be  derived 
from  the  colour  of  the  rash,  for  a  dark  tint  of  the  eruption  is  not  necessarily 
an  unfavourable  sign.  There  is  cause  for  great  anxiety  if  the  temperature 
rise  continuously ;  if  the  throat  affection  be  severe  ;  if  there  be  frequent 
and  long-continued  vomiting  or  copious  dysenteric  diarrhoea  ;  if  nephritis 
appear  early  ;  or  if  there  be  great  diminution  or  suppression  of  the  urinary 
secretion.  Uraemic  symptoms  are  not  so  severe  in  the  child  as  they  are  in 
the  adult.  At  least,  according  to  my  experience,  it  is  not  common  for  a 
child  to  die  of  uraemic  poisoning,  if  judiciously  treated. 

Treatment. — In  cases  where  any  member  of  a  family  is  taken  with 
scarlet  fever,  it  is  of  importance  to  prevent  the  illness  spreading  to  the 
others.  Prompt  isolation  of  the  patient  is  of  course  to  be  insisted  on  ; 
and  it  is  well,  5  the  step  can  be  conveniently  adopted,  to  send  the  other 
children  away  from  the  neighbourhood  of  the  sufferer. 

Various  prophylactic  measures  have  been  recommended  to  arrest  the 
disease  in  the  incubative  stage  and  prevent  its  further  development. 
Belladonna,  which  was  at  one  time  largely  employed  with  this  object,  has 
been  now  proved  to  be  useless.  It  seems  likely,  however,  that  in  arsenic 
we  have  an  agent  of  greater  value.  It  has  been  noticed  that  a  person  who 
is  being  treated  with  arsenic  cannot  be  successfully  vaccinated  ;  and  it  is 
possible  that  the  drug  may  have  a  counteracting  influence  upon  other 
forms  of  infective  matter.  Practitioners  who  have  made  use  of  the  remedy 
with  this  object  speak  favourably  of  its  prophylactic  virtue.  Dr.  W.  G.  Wal- 
ford  has  given  the  drug  largely  to  children  who  had  been  exposed  to  the 
infection  of  scarlatina,  and  states  that  out  of  nearly  a  hundred  such  cases 
in  only  two  did  the  development  of  the  fever  follow,  and  both  cases  were 
extremely  mild.  He  recommends  the  ordinary  liq.  arsenicalis  (P.B.)  in 
as  large  a  dose  as  the  age  of  the  child  will  allow,  with  sulphurous  acid 
( TT|,  xv.-xxx.),  and  a  little  syrup  of  poppy.  The  child  should  take  the  dose 
regularly  three  times  a  day  at  the  first ;  afterwards  less  frequently. 

When  the  disease  actually  declares  itself,  prophylactic  measures  must 
of  course  be  laid  aside.  In  a  malady  such  as  scarlatina,  where  the  gen- 
eral symptoms  are  often  violent,  and  the  complications  are  various  and 
may  be  severe,  the  therapeutic  measures  at  our  disposal  are  necessarily 
very  numerous.  Still,  we  must  depend  for  a  successful  result  more 
upon    vigilant  nursmg  than  upon  the  actual   administration  of   drugs ; 


44  •  DISEASE  I]^T   CHILDRElSr. 

altliougli  these,  especially  when  complications  occur,  are  often  of  sensible 
value. 

However  mild  the  symptoms  may  be,  the  child  should  be  kept  in  bed 
in  a  well-ventilated  room,  from  which  all  carpets,  curtains,  rugs,  cushions, 
and  other  woollen  articles  not  required  for  the  comfort  of  the  patient  have 
been  previously  removed.  In  order  to  prevent  the  spread  of  the  disease,  a 
sheet  kept  wet  with  a  solution  of  carbolic  acid  (one  part  in  forty  parts  of 
water)  should  be  fastened  so  as  to  hang  over  the  door-way  ;  and  care 
should  be  taken  to  disinfect  all  excreta,  soiled  Hnen,  etc.,  before  they  are 
removed  from  the  room.  The  child  may  be  allowed  to  drink  as  often  as 
he  desires  of  pure  filtered  water,  but  the  quantity  taken  at  each  time  of 
drinking  must  be  limited.  His  diet  should  consist  of  milk,  broth,  hght 
puddings,  bread  and  butter,  etc.  The  heat  and  irritation  of  the  skin  is 
greatly  relieved  by  sponging  the  surface  of  the  body  several  times  a  day 
with  tepid  water,  and  afterwards  drying  with  a  soft  towel.  This  is  a  more 
pleasant  operation  than  the  inunction  of  fats,  which  is  sometimes  recom- 
mended, and  is  quite  as  serviceable  to  the  patient. 

In  an  ordinary  case  little  medicine  is  required ;  but  if  the  throat  is 
painful,  a  draught  of  chlorate  of  potash  may  be  ordered.  Should  the 
throat  become  much  inflamed,  and  the  cervical  glands  of  the  neck  swell 
and  be  tender,  the  child  should  be  made  to  suck  ice,  and  hot  applications 
(linseed-meal  poultices,  frequently  renewed)  should  be  applied  to  the 
neck  ;  or  we  may  use  the  cold  compress,  which,  becoming  heated  by  con- 
tact with  the  skin,  acts  in  the  same  way.  Cold  thus  applied  internally, 
while  the  outside  of  the  throat  is  kept  warm,  often  produces  a  rapid 
amelioration  in  the  symptoms.  If,  however,  the  throat  affection,  instead 
of  improving,  becomes  worse,  and  ulceration  is  noticed,  it  will  be  neces- 
saxj  to  apply  some  local  application  to  the  fauces.  In  such  a  case  the 
throat  having  been  carefully  cleansed  with  a  brush  dipped  in  warm  water, 
a  solution  of  nitrate  of  silver  (half  a  drachm  to  the  ounce)  should  be 
applied  freely  to  the  whole  of  the  ulcerated  surface.  Moreover,  any 
special  tdcer  may  be  touched  once  with  the  solid  caustic.  The  weaker 
application  must  be  repeated  every  morning  for  three  or  four  days  ;  and 
in  the  interval  a  solution  of  common  salt  in  water  (half  an  ounce  to  the 
jpint)  can  be  injected  frequently  into  the  fauces.  It  is  very  important  in 
these  cases  to  keep  the  throat  clean  inside,  in  order  to  remove  quickly  the 
poisonous  secretions  thrown  out  from  the  diseased  surfaces  ;  and  frequent 
syringing  or  garghng  of  the  throat  with  a  saline  solution  such  as  the 
above,  which  dissolves  mucus  and  facilitates  the  separation  of  tenacious 
secretions,  will  be  attended  by  marked  benefit.  If  required  to  clean  the 
mucous  surfaces,  the  saline  solution  may  be  applied  from  time  to  time 
with  a  brush.  In  addition  to  these  measures,  disinfecting  applications 
may  be  made  use  of ;  such  as  a  weak  solution  (two  per  cent.)  of  carbolic 
acid,  or  a  lotion  composed  of  liq.  sodse  chlorinatse  (TTj,  xx.  to  the  ounce  of 
water).  In  these  cases  of  severe  sore  throat  it  is  advisable,  as  much  for 
the  sake  of  others  as  for  the  benefit  of  the  patient,  to  keep  the  air  of  the 
room  saturated  with  a  solution  of  carbolic  acid  (one  part  in  thirty  of 
water)  by  Dr.  E.  J.  Lee's  steam  draught  inhaler,  or  some  similar  apjDaratus. 
The  application  of  sulphui-ous  acid  to  the  throat,  as  recommended  by  the 
late  Dr.  Dewees,  is  also  useful.  This  remedy  should  be  used  with  an 
atomizer,  and  the  acid,  pure  or  diluted  with  an  equal  proportion  of  water, 
should  be  sprayed  into  the  throat  for  a  few  minutes  every  two  or  three 
hours. 

If-  there  be  coryza,  the  saline  solution  may  be  injected  into  the  nasal 


SCAELET   FEVER — TREATMENT.  46 

fossse,  or  the  nose  may  be  syringed  once  a  daj  'wiLli  a  weak   solution  di 
nitrate  of  silver  (gr.  v.  to  the  ounce). 

Abscesses  forming  in  the  neck  must  be  opened  directly  fluctuation  is 
detected,  and  be  afterwards  well  poulticed.  If  haemorrhage  occur,  the 
wound  must  be  stuffed  with  lint  soaked  in  perchloride  of  iron.  A  post- 
pharyngeal abscess  must  be  also  opened  early  with  a  large  trocar  and 
cannula. 

If  otorrhoea  be  noticed,  the  meatus  must  be  syringed  out  fi'equently 
during  the  day  with  warm  water.  If  the  tympanic  membrane  be  perfect, 
the  discharge  proceeding  only  from  the  external  canal,  a  syringeful  of 
some  mild  astringent  lotion  should  be  injected  each  time  after  comj)lete 
cleansing.  Glycerine  of  tannin  (one  drachm  to  the  ounce  of  water)  or  a 
weak  solution  of  sulphate  of  zinc  (gr,  iij.  to  the  ounce)  answer  well  for  this 
purpose. 

In  the  case  of  any  of  the  above  complications  quinine  in  fuU  doses 
(gr.  iij.  four  times  a  day  for  a  child  five  years  old)  should  be  given  ;  and 
a  liberal  diet  should  be  allowed,  due  regard  being  had  to  the  patient's 
powers  of  digestion.  When  the  temperature  has  fallen  in  scarlet  fever 
the  child  should  have  meat  once  a  day,  an  egg  or  a  little  bacon  for  his 
breakfast,  and  should  take  plenty  of  milk.  As  long  as  the  water  con- 
tinues clear  we  may  be  sure  that  he  is  not  being  overloaded  with  food  ; 
but  the  appearance  of  a  thick  deposit  of  lithates  should  at  once  make  us 
reconsider  his  dietary,  and  limit  the  quantity  allowed  at  his  meals. 

When  the  throat  affection  is  severe,  iron  seems  more  beneficial  than 
quinine,  if  administered  energetically.  For  a  child  of  this  age  fifteen  to 
twenty  drops  of  the  pernitrate  of  iron  should  be  given  with  glycerine  and 
water  every  three  or  four  hours.  At  the  same  time  brandy-and-egg  mixt- 
ure must  be  supplied  in  such  quantities  as  seem  desu-able,  according  to 
the  degree  of  prostration  of  the  patient.  In  such  cases  children  will  take 
with  benefit  large  quantities  of  the  stimulant.  Strong  beef-tea,  meat 
extract,  etc.,  can  also  be  given. 

If  the  disease  be  ushered  in  with  obstinate  vomiting,  the  symptom  is 
best  reheved  by  sucking  ice.  If  diarrhoea  occur,  oxide  of  zinc  (five  grains 
for  a  child  of  five  years  old)  or  bismuth  (gr.  xv.)  and  chalk  mixture  should 
be  resorted  to.  If  at  the  beginning  of  the  diarrhoea  the  motions  are  lumpy, 
a  mild  aperient,  such  as  a  dose  of  castor-oil  or  a  rhubarb  and.  soda  powder, 
should  be  administered. 

In  cases  of  malignant  scarlet  fever  with  violent  nervous  symptoms 
every  kind  of  treatment  will  unfortunately  be  often  found  to  fail.  If  the 
temperature  be  high,  it  must  be  reduced  by  cold  bathing.  The  child 
may  either  be  placed  in  a  cool  bath  (temperature  of  70°  Fahr.),  and  kept 
there  until  his  teeth  begin  to  chatter  ;  or  affusions  with  water  of  the  same 
temperature  may  be  practised,  as  recommended  by  Currie.  I  prefer  the 
former  method  ;  and  there  is  no  doubt  that  the  immediate  effect  of  the 
bath  in  lowering  the  pulse  and  temperature,  dissipating  the  delirium,  and 
relieving  the  agitation  of  the  patient  is  very  decided.  When  the  temper- 
ature rises  again  and  delirium  returns  the  process  must  be  repeated. 
Unfortunately,  although  there  is  temporary  relief  to  the  symptoms,  the 
patient  is  seldom  cured  by  this  means,  and  usually  falls  after  a  time  into 
a  state  of  prostration  and  collapse,  in  which  he  dies.  A  milder  way  of 
employing  the  same  treatment  is  to  wrap  the  child  in  a  wetted  sheet,  and 
lay  him  upon  a  hard  mattress,  covering  him  merely  with  a  thhi  blanket 
thrown  loosely  over  him.  When  he  shivers  he  should  be  released  and 
returned  to  his  bed.     The  milder  practice  is  suitable  in  the  less  severe 


46  DISEASE   IlSr   CHILDEEW. 

cases,  and  has  a  distinct  effect  in  reducing  tlie  temperature.  It  must  be 
remembered,  however,  with  regard  to  this  question  of  hyper-pyrexia,  that 
children  often  bear  high  temperatures  A^ery  well ;  and  it  is  difficult  to  lay 
down  a  broad  rule  as  to  the  period  at  which  it  is  necessary  to  intervene. 
It  is  better  to  be  guided  in  this  respect  by  the  general  symptoms  than  hj 
the  thermometer.  If,  as  often  happens,  a  child  seems  comfortable  and 
composed,  with  a  temperature  of  105""  or  106°,  there  is  no  occasion  for  any 
step  more  energetic  than  that  of  sponging  the  surface  of  the  body  with 
warm  water  ;  but  if  with  a  lower  temperature  (103°  or  104°)  he  is  deliri- 
ous, agitated,  and  distressed,  the  cold  bath  may  be  used  with  benefit. 
"Wet  packing  is  often  useful  in  these  cases  ;  but  when  thus  enveloped  in 
blankets  the  child's  temperature  must  be  carefully  watched.  If  the  skin 
be  induced  to  act  by  this  means,  and  the  patient  sweat  profusely,  the 
process  is  a  beneficial  one  and  the  temperature  will  fall.  If,  on  the 
other  hand,  the  skin  do  not  act,  the  effect  of  the  packing  is  to  cause- a 
further  increase  in  the  pyrexia.  Therefore,  if  the  temperature  be  found 
to  rise  instead  of  falling,  the  blankets  should  be  at  once  removed.  In 
all  these  cases  the  bath,  of  whatever  kind  it  be,  should  be  supplemented 
by  energetic  stimulation  in  order  to  counteract  the  tendency  to  sudden 
collapse. 

If  the  child  is  from  the  first  in  a  state  of  prostration,  instead  of  the  cold 
bath  the  hot  mustard  bath  may  be  made  use  of  ;  but  such  cases  are  seldom 
benefited  even  temj)oraril3^ 

If  rheumatic  pains  are  complained  of  and  the  joints  swell,  these  parts 
should  be  wrapped  in  cotton  wool  and  covered  with  a  firmly  applied  flannel 
bandage  ;  and  Dover's  powder  should  be  given  at  night  if  the  pains  inter- 
fere with  sleep.  Attention  must  also  be  paid  to  the  state  of  the  bowels. 
Inflammation  of  the  serous  membranes  must  be  treated  upon  ordinary 
jDrinciples. 

If  albummous  nephritis  occur,  energetic  treatment  must  be  adopted  at 
once.  A  mere  trace  of  albumen,  such  as  is  often  met  with  in  cases  of 
scarlatina,  is  of  little  consequence,  and  requires  merely  tonic  treatment ; 
but  the  appearance  of  copious  albumen  in  a  smoky  urine  shows  the  pres- 
ence of  acute  Bright's  disease,  and  is  a  very  different  matter.  We  should 
therefore  at  once  proceed  to  sweat  and  purge  the  patient.  There  is,  per- 
haps, no  condition  in  which  the  beneficial  influence  of  free  purgation  is 
more  striking  than  in  this  complication.  A  child  of  five  years  old  should 
take  every  night  a  dose  of  compound  jalap  powder  (gr.  xxx.-xl.)  alone,  or 
mixed  with  five  grains  of  compound  scammony  powder.  Enough  should 
be  given  to  j^roduce  two  or  three  watery  stools.  In  the  daytime  he  should 
be  wrapped  in  a  sheet  wrung  out  of  tepid  water  and  be  then  well  packed 
in  blankets  ;  taking  at  the  same  time  a  draught  containing  a  solution  of 
acetate  of  ammonia  (  3  j.)  and  antimonial  wine  (TTj,  xx.)  to  instire  the  free 
action  of  the  skin.  His  diet  should  be  simple.  As  long  as  there  is  any 
pyrexia  no  solid  food  should  be  allowed  ;  and  the  patient  should  have  noth- 
ing but  milk  and  broth  with  dry  toast.  Plenty  of  fluid  is  useful.  If  these 
measures  be  adopted,  the  albumen  in  the  majority  of  cases  will  be  found 
to  disappear  very  quickly  from  the  urine.  Should  it,  however,  persist,  and 
the  renal  disorder  seem  to  be  passing  into  a  chronic  state,  iron  and  ergot 
are  indicated  ;  or  tlu-ee  grains  of  the  hydrate  of  chloral  may  be  given  (for 
a  child  of  five  years  old)  three  times  a  day.  In  cases  of  ursemic  convulsions 
purging  and  sweating  carried  out  briskly  are  of  equal  service,  and  will 
usually  quickly  relieve  the  symptoms,  especially  if  aided  by  a  diuretic.  The 
following  is  a  serviceable  form  : 


SCARLET   FEVER — TREATMENT.  47 

IJ .  Liq.  ammoniae  acetatis Til  xxx. 

Potassse  acetatis , gr.  v. 

Sp.  juniperis TTl,  v. 

Sp.  setheris  nitrosi TT[  xx. 

Glycerin! Til,  xx, 

Aquam  ad  §  ss.  M.  Ft.  haustus. 
To  be  taken  every  four  hours  (for  a  child  of  five  years  old). 

A  good  diuretic  for  children  is  digitalis  ;  and  the  drug  is  well  borne  in 
«arly  life.  Five  drops  of  the  tincture  given  three  times  a  day  with  an  equal 
quantity  of  spirits  of  juniper  may  be  employed.  Jaborandi  and  its  alkaloid 
pilocarpine  are  useful  in  these  cases ;  and  can  be  given  either  by  the 
mouth  or  by  subcutaneous  injection.  The  most  convenient  way  of  admin- 
istration is  to  make  a  fresh  solution  of  the  nitrate  or  hydrochlorate  of 
pilocarpine  in  water  of  the  strength  of  one  grain  to  twenty-four  minims. 
Of  this  solution  three  drops  (one-eighth  of  a  grain)  can  be  injected  sub- 
€utaneously,  and  is  a  suitable  dose  for  a  child  of  five  years  of  age.  Children 
bear  this  remedy  well.  If  the  solution  is  freshly  made,  copious  sweating 
follows  the  injection  ;  there  is  often  profuse  salivation  ;  and  the  secretion 
of  urine  is  greatly  augmented.  The  child  should  lie  between  blankets,  so 
as  to  encourage  the  action  of  the  skin.  The  dose  may  be  repeated  every 
day,  if  necessary.  It  often  excites  nausea  and  vomiting,  but  this  is  imma- 
terial. 

During  the  stage  of  desquamation  measures  should  be  taken  to  hasten 
the  separation  of  the  epithelium.  The  child  should  be  oiled  all  over  the 
body  every  night  with  carbolized  oil  (one  part  of  the  acid  to  twenty  parts 
of  ohve-oil),  and  this  should  be  well  rubbed  into  the  skin.  Afterwards  he 
should  be  thoroughly  washed  with  soap  in  a  warm  bath.  If  this  be  carried 
out  in  a  warm  room,  there  is  no  fear  of  a  chill. 

Even  in  mild  cases  the  child  should  keep  his  bed  for  three  weeks,  and 
his  room  for  a  month  at  least,  from  the  beginning  of  his  illness  ;  and  until 
the  peeling  has  quite  ceased  the  patient  is  unfit  to  associate  with  healthy 
persons.  It  must  be  remembered  that  desquamation  may  linger  long  about 
the  wrists  and  ankles,  the  fingers  and  the  toes  ;  and  that  a  considerable 
time  may  elapse  before  the  mucous  membrane  of  the  throat  has  completely 
recovered  its  normal  state.  When  the  child  is  finally  pronounced  to  be 
weU,  it  is  advisable  to  send  him  to  the  sea-side  for  change  of  air  before  he 
resumes  his  ordinary  habits  and  mode  of  life. 


CHAPTEE  lY. 

CHICKEX-POX- 

Chickex-pox  or  varicella  is  seldom  seen  except  in  yoiing  subjects.  It  is  an 
infectious  disorder  which  occiu's  generally  in  epidemics,  and  attacks  by 
preference  children  aged  from  two  to  six  years.  At  one  time  it  was  sup- 
posed to  be  a  form  of  modified  small-pox,  but  few  ai-e  now  of  this  opinion, 
for  the  evidence  against  it  is  overwhelming.  Attempts  have  been  made  to 
impart  the  disease  by  inoculation,  but  without  success. 

Symptoms. — After  a  period  of  incubation,  varying  from  seven  to  four- 
teen days,  the  child  is  noticed  to  be  feverish,  and  within  the  next  four-and- 
twenty  hours  a  number  of  small  rosy -red  spots  appear  on  the  chest  and 
over  the  body  generally.  These  ai-e  slightly  elevated,  and  number  on  the 
first  day  fifteen  or  twenty.  In  the  course  of  a  few  hours — in  any  case  by 
the  next  morning — the  jDapule  has  changed  into  a  vesicle  or  roundish  bleb 
which  is  filled  with  clear  serum.  It  has  sometimes  a  very  faint  pink 
areola  round  its  cu'cumference.  At  the  same  time  other  papules  have  ap- 
peared, more  numerous  than  on  the  first  day.  These  in  theii'  tui-n  become 
converted  into  clear  blebs.  In  this  way  every  morning  finds  a  fresh  crop 
of  red  spots,  and  of  fresh  blebs  formed  from  the  red  spots  of  the  previous 
day.  The  change  from  red  sj)ot  to  bleb  may  take  place  very  C]uickly  ;  in 
fact,  the  rash  has  sometimes  been  described  as  vesicular  from  the  first. 
In  any  case  it  is  completed  within  ten  or  twelve  houi's  of  the  appearance  of 
the  red  papule.  The  spots  ap^Dear  in  no  reg-ular  order,  but  are  scattered 
about  all  parts  of  the  body  and  limbs,  and  may  even  be  seen  beneath  the 
hair  on  the  scalp.  They  are  also  occasionally  found  inside  the  mouth, 
on  the  soft  palate,  the  inner  side  of  the  cheeks  and  lips,  and  at  the  sides 
of  the  tongue  ;  but  when  seated  on  mucous  membrane  the  vesicle  changes 
very  rapidly  to  a  small  round  ulcer.  After  appearing  in  successive  crops 
for  four  or  five  days,  fi-esh  spots  cease  to  be  seen.  The  changes  which 
each  individual  spot  rmdergoes  are  as  follows  : — it  increases  in  size  .for  a 
day  or  two,  and  then  its  liquid  contents,  fi-om  clear,  like  pui-e  water,  be- 
come milky.  Some  burst  and  form  crusts ;  others  present,  after  a  day  or 
two,  a  speck  of  scab  on  the  summit,  which  to  a  hasty  glance  gives  a  false 
appearance  of  umbilication  ;  the  vesicle  then  dries  up  and  leaves  a  thin 
crust,  which  falls  off  after  a  few  days.  No  scar  is  left,  as  in  variola,  unless 
the  child  have  irritated  the-  skin  by  scratching  ;  in  which  case  a  shallow 
pit  may  be  seen  in  the  situation  of  the  scab.  It  is  difficult  to  prevent  the 
child  from  scratching  the  spots,  for  the  eru^Dtion  is  accompanied  by  con- 
siderable ii'ritation. 

The  amount  of  fever  varies.  At  the  beginning  the  temperatui-e  may 
rise  as  high  as  102^,  especially  if  the  rash  is  slow  to  appear.  After  the  first 
day  or  two,  however,  the  pyrexia  subsides  considerably,  and  is  seldom 
higher  than  99.5°  during;  the  remainder  of  the  illness.     In  some  cases  a 


CHICKETSr-POX — DIAGNOSIS.  49 

sliglit  exacerbation  occurs  with  the  maturation  of  the  vesicles,  but  the 
temperature  soon  returns  to  the  normal  level.  In  the  large  majority  of 
cases  the  constitutional  disturbance  is  of  the  slightest.  After  the  crusts 
have  fallen  the  temperature  sinks  to  a  lower  level  than  in  health. 

The  duration  of  the  disorder  is  ten  days  or  a  fortnight,  counting  from 
the  preliminary  fever  to  the  final  fall  of  the  crusts.  Afterwards  the  child 
may  be  left  in  a  weakly  state  for  some  time  ;  and  dehcate  children  may 
have  the  outbreak  of  serious  disease  determined  by  this  apparently  trilling 
complaint.  Thus,  I  have  known  acute  tuberculosis  to  succeed  after  a  very 
rihort  interval  to  an  attack  of  chicken-pox. 

In  exceptional  cases  the  complaint  is  not  over  so  quickly.  Mr.  J". 
Hutchinson  was  the  first  to  draw  attention  to  the  gangrenous  eruptions 
which  sometimes  occur  in  connection  with  the  chicken-pox.  This  dan- 
gerous complication  is  not  confined  to  weaklj^  ill-nourished  children,  al- 
though it  is  most  common  in  them.  It  is  no  doubt  connected  with  the 
curious  tendency  to  spontaneous  gangrene  sometimes  met  with  in  chil- 
dren, and  described  in  another  chapter. 

In  gangrenous  varicella  the  vesicles,  instead  of  drying  up  in  the  ordi- 
nary way,  become  black  and  get  larger,  so  that  a  number  of  rounded  black 
scabs,  with  a  diameter  of  half  an  inch  to  an  inch,  are  scattered  over  the 
surface  of  the  body.  If  a  scab  be  removed  it  is  seen  to  cover  a  deep  ulcer. 
Around  it  the  skin  is  of  a  dusky  red  color.  All  the  vesicles  do  not  take  on 
the  gangrenous  action,  so  that  we  find  many  varicellous  scabs  of  ordinary 
appearance  mixed  up  with  the  blackened  crusts.  The  gangrenous  process 
often  penetrated  deeply  through  the  skin  to  the  muscles,  but  under  some 
of  the  scabs  the  ulceration  is  more  shallow.  These  cases  are  very  fatal. 
Mr.  Warrington  Ha  ward  has  reported  the  case  of  a  weakly  baby  of  twelve 
months  old,  who  weighed  onlj  six  pounds  and  a  half.  This  child  was  at- 
tacked with  gangrenous  varicella  and  died  in  a  few  days  of  pyaemia  with 
secondary  abscesses  in  the  lungs. 

Diagnosis. — It  is  often  a  very  difficult  matter  to  distinguish  between 
chicken-pox  and  modified  small-pox.  If  the  eruption  follows  very  rapidly 
upon  the  first  signs  of  fever,  the  disease  is  probably  varicella,  for  in  the 
case  of  varioloid  the  rash  is  usuall}^  preceded  by  two  or  three  days  of  fever 
and  malaise  with  vomiting  ;  and  the  pain  in  the  back  may  be  as  intense  as 
in  the  unmodified  form  of  the  disease.  But  there  are  many  excejDtions  to 
this  rule,  for  in  some  cases  of  varioloid  the  normal  duration  of  the  pre- 
emptive period  is  considerably  shortened.  Again,  the  spots  in  varioloid, 
as  in  variola,  are  grouped  in  threes  and  fives,  while  in  varicella  their  distri- 
bution is  more  irregular.  Then,  the  papule  in  varioloid  is  always  shottj 
and  hard.  In  varicella  it  is  peculiarly  soft,  and  always  disappears  on. 
stretching  the  skin.  If  there  be  an  elevation  left  after  the  faU  of  the  scab,, 
it  is  conclusive  in  favoiir  of  modified  small-pox  ;  while  a  subnormal  tem- 
perature occurring  as  early  as  the  tenth  day  would  point  rather  to  varicella 
than  to  varioloid.  According  to  Mr.  Macuna,  the  varicellous  vesicle  is  uni- 
locular, and  can  be  emptied  b}^  one  touch  of  a  needle.  The  vesicle  in 
small-pox,  on  the  contrary,  is  always  multilocular,  and  cannot  be  emptied 
by  a  single  puncture.  In  case  of  doubt  this  difference  will  serve  as  a  dis- 
tinguishing mark. 

It  is  important  to  be  aware  that  a  shallow  pit  or  scar  may  be  left  here 
and  there  upon  the  skin  after  undoubted  varicella.  Pitting  may  occur- 
in  any  case  where,  from  the  irritation  of  continued  scratching,  or  from 
some  constitutional  peculiarity  of  the  patient,  ulceration  of  the  skin  has 
been  set  up  in  the  site  of  a  vesicle. 


50  DISEASE   IN   CHILDEEN. 

Gangrenous  varicella  is  distinguislied  by  the  history  of  the  case,  and  the 
appearance  of  ordinary  varicellous  scabs  mixed  up  with  the  blackened  and 
gangrenous  crusts. 

Treatment. — A  child  attacked  by  chicken-pox  must  be  removed  from 
other  children,  and  prevented,  if  possible,  from  picking  or  scratching  the 
spots.  If  there  be  much  fever,  he  should  be  confined  to  bed  and  his 
bowels  must  be  attended  to.  When  the  disease  is  at  an  end,  the  child  wiU 
require  a  tonic,  such  as  quinine  or  iron.  If  convenient,  he  may  be  taken 
to  the  sea-side  ;  and  if  there  be  any  consvunptive  tendency  in  the  family 
change  of  air  diu-ing  convalescence  is  not  unimportant. 

In  cases  of  gangrenous  varicella  little  can  be  done  beyond  supporting 
the  strength  with  good  food  suitable  to  the  age  and  degree  of  feebleness  of 
the  patient,  and  giving  the  brandy-and-egg  mixture  as  often  as  is  requii-ed. 
If  the  gangrenous  crusts  are  few  in  number,  the  scabs  may  be  removed 
and  the  underljdng  ulcer  filled  with  iodoform  powder,  as  recommended  by 
Parrot  for  gangrene  of  the  vulva. 


CHAPTER   V. 

COW-POX.— VACCINATION. 

The  cow-pox,  or  vaccinia,  is  a  disease  with  is  natural  to  the  milch  cow, 
but  never  occurs  in  the  human  subject  except  as  the  result  of  direct  vacci- 
nation. In  the  cow  it  appears  on  the  teats  and  udder  as  isolated  spots, 
which  at  first  are  papular,  but  afterwards  pass  through  the  vesicular  and 
pustular  stages,  as  in  true  small-pox.  They  scab  on  the  thirteenth  or  four- 
teenth day,  and  faU  off  in  the  following  week,  leaving  pits  on  the  skin. 
This  disease  is  now  satisfactorily  proved  to  be  the  real  small-pox,  altered  in 
character  and  modified  by  its  passage  through  the  animal,  but  still  capable, 
when  conveyed  to  the  human  subject,  of  imparting  as  much  protection  as 
would  be  derived  from  a  direct  attack  of  the  original  disease. 

It  is  now  a  familiar  story  how  Edward  Jenner,  then  living  as  apprentice 
to  a  surgeon  in  Gloucestershire,  determined  to  investigate  the  truth  of  a 
belief,  current  in  the  neighbourhood,  that  milkers  who  had  become  inoc- 
ulated with  cow-pox  in  the  pursuit  of  their  calling,  were  no  longer  suscep- 
tible to  the  contagion  of  small-pox ;  and  how,  by  careful  observation  and 
experiment,  he  succeeded  in  establishing  the  important  conclusions — that 
cow-pox  communicated  by  inoculation  to  the  human  subject  did  actually 
confer  immunity  from  small-pox  ;  also  that  the  disease,  so  engrafted,  might 
be  transmitted  indefinitely  from  person  to  person  without  any  abatement  of 
its  protective  power.  Since  Jenner's  time  the  practice  of  vaccination  has 
become  universal,  and  to  this  great  discovery  we  owe  it  that  small-pox,  as 
it  used  to  be,  with  all  its  dreadful  consequences,  is  almost  unknown  in  the 
present  day. 

Symptoms  and  Course.  — After  the  introduction  of  the  lymph  under  the 
skin  of  a  child  previously  unvaccinated  the  following  is  the  course  of  the 
induced  disorder.  For  two  days  no  change  takes  place,  but  at  the  end  of 
the  second  day,  or  beginning  of  the  third,  a  small  elevated  papule  is  seen 
at  the  site  of  the  puncture.  This  enlarges,  and  by  the  fifth  or  sixth  day 
has  become  a  circular  raised  pearly-gray  vesicle,  with  a  depression  in  the 
centre.  The  vesicle  grows,  and  by  the  eighth  day  is  fully  developed.  It  is 
then  seen  as  a  flattened,  round,  gray-colored  vesicle,  still  depressed  in  the 
centre  and  filled  with  a  colorless  lymph.  It  does  not  remain  stationary, 
but  begins  at  once  to  lose  its  transparency  ;  a  red  areola  forms  round  its 
base  and  quickly  spreads,  so  that  by  the  tenth  day  the  vesicle  is  found 
seated  on  a  hardened  red  base,  with  the  red  areola  extending  for  one  or 
more  inches  over  the  skin  around.  The  vesicle  has  now  become  a  j)ustule 
with  purulent  contents,  and  around  it  the  subcutaneous  tissue  is  hard  and 
swollen.  After  the  tenth  day  the  areola  gradually  fades  ;  the  fluid  contents 
of  the  pustule  undergo  absorption  ;  and  by  the  fourteenth  or  fifteenth  day 
a  scab  has  formed,  which  gradually  loosens  and  becomes  detached.  The 
crust  usually  falls  in  about  three  weeks  from  the  time  of  puncture,  and  in 
its  place  is  seen  a  round  sunken  scar  pitted  with  little  depressions. 


52  DISEASE   IX    CHILDEEK. 

The  disease  is  at  first  purely  local,  but  aftei'Tvards  becomes  general 
According  to  Dr.  Squire  a  continuous  rise  of  temjDeratui-e  begins  on  the 
fourth  or  fifth  day.  This  suddenly  increases  on  the  eighth  day,  and  as 
suddenly  falls  a  day  or  two  afterwards,  when  the  areola  has  ceased  to  ex- 
tend itself.  The  maturation  of  the  vesicle  is  also  accompani^l  by  other 
signs,  showing  that  the  disease  has  begun  to  aifect  the  system.  The  child 
is  restless  and  uneasy ;  there  is  some  digestive  disturbance  ;  and  the 
lymphatic  glands  in  the  armpit  become  tender.  Sometimes  a  roseolous 
red  rash  makes  its  appearance  on  the  affected  hmb,  and  may  extend  to 
the  other  extremities.     This  rash  may  become  papular  or  even  vesicular. 

The  above  is  the  course  of  the  disease  when  the  inoculating  lymjoh  is 
taken  from  another  child.  Some  practitioners  prefer  to  use  lymph  ob- 
tained dii'ectly  from  the  cow.  But  -uith  "  piimaiy "'  lymph  there  is  more 
difficulty  in  operating  successfully ;  and  when  the  vaccination  takes  effect, 
the  constitutional  symptoms  are  more  severe.  There  is  also  another  dif- 
ference. "With  such  lymph  the  whole  process  is  retarded.  The  papule 
does  not  appear  until  a  week  or  even  a  longer  time  has  elapsed,  and  the 
areola  does  not  become  complete  until  the  eleventh  or  even  the  foui'teeuth 
day.  The  swelhng  and  hardness  around  the  pustule  are  greater,  and  the 
secondary  rashes  are  more  frecjuently  seen.  The  scabbing  stage  is  also 
prolonged,  and  the  crust  may  not  fall  for  a  month  or  six  weeks  from  the 
day  of  operation. 

Even  when  humanized  lymph  is  made  use  of,  the  process  is  occa- 
sionally retarded.  This  may  be  the  case  when  dried  lymph  is  employed, 
and  is  invariably  seen  if  the  patient  happen  to  be  incubating  measles  or 
scarlatina.  Sometimes,  too,  it  appeal's  to  be  owing  to  a  constitutional 
peculiarity.  Mere  retardation  does  not,  however,  affect  the  value  of  the 
result  if  the  development  of  the  induced  disease  be  noiToaL  Instead  of 
being  retaixled,  the  process  may  be  accelerated  ;  but  this,  again,  is  imma- 
terial, provided  the  course  of  the  pock  be  reg-ular.  If,  however,  for  what- 
ever reason,  the  coui'se  of  the  disease  be  not  regular,  and  the  pock  be  in 
any  way  incomplete,  the  result  must  be  looked  upon  as  unsatisfactoiy, 
and  the  protection  so  afforded  cannot  be  relied  upon.  Vaccination  is  apt 
to  be  rendered  irregular  by  the  presence  of  acute  febrile  disease  ;  of 
diarrhoea ;  or  of  certain  skin  diseases,  especially  hei'pes,  eczema,  intertrigo, 
lichen,  and  strophulus.  In  all  such  cases,  directly  the  child's  health  is 
restored,  the  operation  should  be  repeated.  Unfortunately  it  will  then 
often  fail ;  for  after  a  spurious  vaccination  the  child  may  be  left— tem- 
porarily, at  least — insusceptible  to  the  action  of  the  lymph. 

In  cases  of  re  vaccination  the  result  is  often  iiTegular.  The  whole 
process  is  then  hiuTied.  The  papule  appears  early ;  the  vesicle  is  fully 
developed  by  the  fifth  or  sixth  day  ;  and  then  at  once  declines.  On  the 
eighth  day  a  scab  forms,  and  becomes  detached  a  day  or  two  later ;  so 
that  in  less  than  a  fortnight  the  disease  has  inin  through  aU  its  stages. 
With  this,  the  constitutional  symptoms  are  more  severe,  and  the  itching 
and  local  discomfort  greater,  than  in  cases  where  the  inoculation  is  prac- 
tised for  the  first  time. 

Protective  Value  of  Vaccination. — Effectually  performed,  vaccination  is, 
in  the  majority  of  cases,  a  permanent  protection  against  small-pox  ;  that  is 
to  say,  the  protection  afforded  by  it  is  as  great  as  that  fm-nished  by  an 
actual  attack  of  variola.  Jenner  himself  never  claimed  that  it  would  do 
more  than  this.  As  a  rule,  an  individual  who  has  been  successfulh'  and 
sufficiently  vaccinated  is  either  insusceptible  to  the  contagion  of  small- 
pox, or  .is  capable  of  taking  the  disease  only  in  a  mild  and  modified  fonn. 


CO^V-POX — VACCI]S'ATIOX.  53 

It  is,  then,  very  impoi-tant  to  ascertain  what  constitutes  an  efficient  -vac- 
cination. This  question  has  been  answered  by  Dr.  Marson,  who  found,  as 
a  result  of  thii'ty  years'  observation  of  small-pox  cases  in  the  London  Fever 
Hospital,  that  while  in  unvaccinated  persons  the  mortahty  was  as  high  as 
37  per  cent.,  the  percentage  gradually  diminished  in  exact  proportion  to 
the  number  and  completeness  of  the  vaccination  cicatrices  ;  so  that  in 
persons  who  could  show  four  or  more  well-marked  scars  the  mortahty 
was  only  .55  per  cent.  It  should  therefore  be  the  aim  of  every  vaccinator 
to  produce  foior  or  five  genuine  well-developed  vesicles  upon  the  arm  of 
the  patient.  With  less  than  this  number  the  vaccination,  although  it  may 
be  successful,  cannot  be  considered  to  be  sufficient,  nor  the  protection  as 
complete  as  it  can  be  made.  As  a  further  precaution  it  is  usual  to  re- 
Vaccinate  the  individual  after  he  has  attained  the  age  of  puberty.  Should 
this  be  unsuccessful,  it  is  advisable  to  rej)eat  the  operation  if  at  any  time 
the  person  become  liable  to  be  exposed  to  the  contagion  of  small-pox ; 
esjDecially  if  upon  examination  of  the  arms  he  is  seen  to  bear  only  imper- 
fect evidence  of  a  former  vaccination.  The  protective  power  of  vaccina- 
tion is  well  seen  in  the  following  figures,  kindly  supphed  me  by  my 
friend  Dr.  Twining.  The  cases  were  under  the  care  of  Dr.  Gayton,  of  the 
Homerton  Small-pox  Hospital.  Between  1871  and  1878,  1,574  children 
came  under  observation,  suffering  from  small-pox.  Of  these,  211  had  been 
efficiently  vaccinated,  and  one  of  them  died  :  396  had  been  imperfectly 
vaccinated,  and  of  these  39  died :  179  were  said  to  have  been  vacci- 
nated, but  bore  no  marks ;  of  these  46  died :  788  were  known  never  to  have 
been  vaccinated,  and  of  these  385  died.  Taking  the  last  two  groups  to- 
gether, the  mortahty  in  unvaccinated  children  was  44  per  cent,  under  ten 
years  of  age. 

Method  of  Vaccinating. — The  lymph  used  should  be  taken  from  the  arm 
of  a  healthy  child  at  some  time  between  the  sixth  and  eighth  day  of  vesica- 
tion, while  the  vesicle  still  retains  its  purity  and  transparency.  After  the 
eighth  day  it  should  not  be  used.  The  child,  the  subject  of  the  operation, 
should  be  in  good  health.  If  he  be  poorly,  esj)ecially  if  he  be  feverish,  or 
be  suffering  from  some  skin  eruption,  the  operation  should  be  postjDoned. 
It  was  Jenner's  own  direction  to  sweep  away  all  eruptions  before  inserting 
the  lymph.  This  rule  is  a  very  important  one,  for  although  the  vaccina- 
tion may  possibly  take  effect,  it  is  more  likely  that  it  will  fail,  and  a  spurious 
vaccination  may  render  the  child's  system  insusceptible  to  the  vaccine 
lymj)h  without  affording  the  desired  protection  against  small-pox.  Many 
methods  of  inserting  the  lymph  are  now  in  use.  The  simplest,  and  perhaps 
the  best,  is  to  make  three  separate  punctures  on  each  arm,  inserting  the 
point  of  a  perfectly  clean  lancet,  moistened  with  fresh  lymph,  sufficiently 
deeply  to  draw  a  little  blood.  In  making  the  punctures  the  skin  is  stretched 
between  the  finger  and  thumb,  and  the  point  of  the  lancet  is  inchned  down- 
wards, so  as  to  enter  the  skin  obliquely.  If  fresh  lymph  cannot  be  obtained 
from  the  arm  of  another  child,  lymph  stored  in  capillary  tubes,  or  dried  on 
ivory  points,  may  be  used.  The  dry  points  must  be  first  well  moistened 
with  water,  and  then  inserted  into  the  punctures  made  by  the  lancet.  As 
many  should  be  used  as  there  are  punctures  made  ;  and  the  points  should 
be  pressed  down  into  the  little  wounds  and  allowed  to  remain  for  a  minute. 
On  being  withdi-awn,  they  should  be  pressed  against  the  sides  of  the  punc- 
ture, so  as  to  insure  the  lymph  being  left  in  the  skin. 

Occasional  Sequeke  of  Vaccination. — Sometimes  erysipelas  has  been  set 
up  by  vaccination,  and  even  pysemia  has  been  knoAvn  to  follow,  and  cause 
the  death  of  the  child.     These  unfortunate  consequences  are  not  to  be 


54  DISEASE  IN"   CHILDREN. 

attributed  necessarily  to  any  carelessness  or  awkwardness  on  the  part  of 
the  operator,  nor  to  any  impurity  in  the  lymph  employed.  They  are  due 
to  the  constitutional  state  of  the  child  at  the  time  of  the  operation — a  state 
in  which  the  puncture  of  the  lancet  is  followed  by  these  untoward  accidents 
just  as  any  other  trifhng  operation  might  be  followed  by  tkem.  A  roseolous 
and  papular  rash  has  been  ah-eady  referred  to  as  sometimes  following 
the  maturation  of  the  pustule  ;  but  other  rashes,  such  as  eczema  and  the 
various  skin  eruptions  to  which  children  are  liable,  may  be  seen  after 
vaccmation.  Tliese  rashes  are  always  attributed  by  parents  to  the  insertion 
of  the  vaccine  lymph.  In  some  cases  vaccination  may  have  been  indirectly 
a  cause  of  the  skin  affection  by  lowering  the  child's  general  health — a 
result  which  in  childhood  is  apt  to  follow  any  feverish  attack ;  but  often 
the  occiuTeuce  of  the  eruption  at  a  short  interval  after  the  vaccination  is  a 
mere  coincidence,  and  is  owing  to  an  entirely  different  cause.  In  out- 
jDatients'  rooms  of  hospitals  it  is  not  uncommon  to  find  even  scabies  attrib- 
uted to  a  recent  vaccination. 

Sj'philis  and  scrofula  are  said  to  have  been  conveyed  from  child  to  child 
by  the  vaccine  lymph.  With  regard  to  the  first  of  these  diseases,  it  was 
long  denied  that  such  transmission  was  possible.  Experiments  were  made, 
and  in  France  children  were  deliberately  vaccinated  with  lymph  taken 
from  other  children  suffering  from  inherited  syphilis ;  but  in  no  case  was 
syphilis  found  to  be  communicated  by  the  operation.  Many  cases,  how- 
ever, have  been  since  published  which  leave  no  doubt  that  commvmication 
of  the  sj^Dhihtic  virus  may  take  place  by  this  means.  The  old  notion  that 
the  fact  of  a  vaccine  vesicle  undergoing  its  normal  development  and  pre- 
senting its  normal  appearance  is  distinct  proof  that  the  lymph  within  it  is 
uncontaminated  by  foreign  virus,  appears  to  be  a  correct  one.  In  syphihtic 
children  vesicles  may  assume  this  appearance,  and  are  then  incapable  of 
transmitting  any  disease  other  than  the  cow-pox.  If,  however,  in  taking 
lymph  from  these  vesicles,  the  puncture  be  made  carelessly,  and,  with  the 
lymph,  some  of  the  blood  be  taken  up  by  the  point  of  the  lancet  and  inocu- 
lated into  a  healthy  child,  syj)hihs  may  foUow.  No  doubt  many  of  the 
cases  in  which  a  s^^hilitic  rash  has  followed  vaccination  have  occurred  in 
children  the  subjects  of  inherited  syphihs,  in  whom  the  febrile  movement 
induced  by  the  process  of  vaccination  has  determined  the  outbreak  of  an 
ah'eady  existing  disorder.  So  also  in  scrofulous  children,  a  httle  derange- 
ment of  the  health  will  often  rouse  ujd  the  latent  cachexia,  which  but  for 
this  misfht  have  remained  dormant  a  httle  longer. 


CHAPTEE  YL 

SMALL-POX. 

Owing  to  the  beneficent  discovery  of  Edward  Jenner  the  full  teiTors  of 
small-pox  as  it  used  to  prevail  can  now  hardly  be  realized.  In  unvacci- 
nated  persons,  and  those  upon  whom  the  operation  has  been  performed  im- 
perfectly, the  disease  may  stOl  rage  with  all  its  natural  violence,  but  in  or- 
dinary cases  the  form  of  the  disease  met  with  is  the  milder  variety  which 
is  called  varioloid.  It  is  the  same  disease  as  variola,  although  modified 
more  or  less  by  occurring  in  a  subject  partially  protected  by  vaccination. 

Small-pox  is  one  of  the  most  infectious  of  the  acute  specific  fevers,  and  in 
this  respect  the  modified  form  is  as  dangerous  as  true  variola.  The  patient 
seems  to  be  capable  of  communicating  the  disease  even  before  the  eruption 
appears,  probably,  therefore,  from  the  very  beginning  of  the  early  fever. 
He  also  continues  to  be  a  source  of  danger  to  others  as  long  as  any  par- 
ticle of  scale  or  scab  remains  attached  to  his  body  after  the  subsidence  of 
the  disease.  One  attack  usually  protects  against  a  second,  but  it  is  far 
from  uncommon  for  a  person  to  take  the  fever  two  or  even  three  times. 

Morbid  Arlatomy. — As  in  most  of  the  infectious  fevers,  the  blood  in 
fatal  cases  is  dark  and  coagulates  imperfectly ;  fibrinous  clots  are  often 
found  in  the  right  ventricle  of  the  heart ;  and  in  very  severe  cases  hsemor- 
rhagic  extravasations  are  scattered  about  in  the  loose  tissue  beneath  the 
serous  and  mucous  membranes.  Internal  organs,  such  as  the  heart,  liver, 
and  spleen,  are  either  pale,  flabby,  and  soft,  or  deeply  congested.  The 
mucous  membranes,  especially  of  the  air-passages,  are  intensely  hj'persemic, 
and  are  thickened,  softened,  and  sometimes  ulcerated.  Their  epithehum  is 
partially  separated,  and  their  surface  is  covered  with  a  brown  tenacious 
mucus.  The  same  condition  may  be  found  in  the  mucous  membrane  of 
the  nasal  fossse,  the  mouth,  fauces,  and  gullet.  In  all  of  these  parts  small 
excoriations  may  be  noticed.  They  are  small  round  spots  on  the  mucous 
surface,  either  covered  by  a  whitish  false  membrane  or  presenting  a  round 
point  of  superficial  ulceration.  These  are  probably  due  to  an  eruption  on 
the  mucous  membrane  of  a  like  nature  to  that  which  takes  place  upon  the 
skin.  No  such  appearances  are  seen  upon  the  gastro-intestinal  mucous 
membrane,  but  the  intestinal  follicles  and  the  glands  of  Peyer's  patches  are 
large  and  projecting.  The  lungs  are  often  intensely  congested,  and  are 
sometimes  the  seat  of  pneumonia.  Moreover,  the  pleura  of  one  side  may  be 
filled  with  sero-purulent  fluid. 

In  the  skin  the  morbid  changes  are  as  follows  :  A  punctiform  hyper- 
semia  takes  place  at  various  spots  which  extends  through  the  cutis  to  the 
rete  rducosum.  The  cells  of  this  part  sweU  and  proliferate,  so  that  a  solid 
sharply  defined  nodule  is  formed  at  the  inflamed  spot.  Next,  the  epider- 
mis is  raised  up  by  fluid  exudation  into  a  vesicle.  If  this  be  formed  round 
a  haii'-folUcle  or  sweat-gland,  it  is  urabilicated  in  consequence  of  the  sum- 
mit being  held  down  by  the  duct.     The  vesicle  is  multilocular,  for  its  in- 


56  DISEASE   IX   CHILDREN. 

terior  is  cliTided.  into  several  cliambers  by  delicate  jjartitions.  These  are 
not  fibrinous,  as  used  to  be  thought,  but  are  formed  by  compression  of 
the  altered  cells  by  the  efiused  fluid.  They  disappear,  as  well  as  the  um- 
bilication,  when  the  process  of  maturation  is  complete.  The  vesiculai-  fluid 
contains  many  leucocytes  and  some  red  blood  coi-puscles.  As  the  j)rolif- 
eration  of  the  cells  of  the  rete  mucosum  continues,  the  fluid  becomes 
jDui-ulent  and  the  vesicle  is  changed  into  a  pustule.  The  time  skin  is  some- 
times desti'oyed  by  this  suppui^ative  process  to  some  dej)th,  and  there  is  a 
depressed  permanent  scar  then  left  after  the  fall  of  the  scab. 

Syiiiptoms. — The  period  of  incubation  of  small-pox  when  contracted  by 
infection  is,  according  to  ]\Ii".  Marson,  thirteen  times  twenty-four  hours, 
i.e.,  twelve  whole  days  and  parts  of  two  others.  If  the  disease  is  produced 
by  inoculation,  the  period  is  shortened  to  seven  or  eight  days.  During 
this  stage  there  are  no  symptoms  in  ordinaiy  cases,  although  a  certain 
amount  of  mitability  and  peevishness  is  sometimes  noticed,  not  usual  with 
the  child  and  indicative  of  uneasiness  ;  but  no  definite  symptoms  can  be 
observed.  On  the  fourteenth  day  the  fii'st  decided  indication  of  the  illness 
appears  and  the  stage  of  invasion  begins.  Chilhness  mth  a  rise  of  tem- 
perattu'e,  sickness  often  distressing,  and  severe  pains  in  the  back  and  loins, 
sometimes  in  the  Hmbs  as  well,  ai-e  the  characteristic  features  of  this 
period.  The  j)ain  in  the  back  may  be  associated  with  temporary  para- 
jDlegia,  and  is  often  combined  in  children  ^^^ith  incontinence  of  uiine  and 
fseces.  Other  symptoms  ai'e  :  thii'st,  loss  of  appetite,  a  coated  tongue, 
grinding  of  teeth,  frontal  headache,  and  constipation  or  diarrhoea.  A 
severe  amount  of  nervous  distui'bance  is  often  seen,  and  the  child  may  be 
thrown  into  -^-iolent  and  repeated  con^^Tilsions  with  intermediate  delirium 
and  stupor.  The  violence  and  frecjuency  of  these  attacks  are  not  to  be  re- 
lied upon  as  an  index  of  the  severity  of  the  illness  which  is  to  follow,  as 
they  are  probably  dejDendent  less  ujjon  the  intensity  of  the  variolous  jDoison 
than  upon  the  natural  nervous  sensibility  of  the  child.  A  little  giii,  aged 
six  years,  began  to  have  fits  on  November  27th  ;  they  continued  until  the 
29th.  Between  the  convulsive  seizures  the  child  was  drowsy  and  stupid, 
and  often  vomited.  On  the  29th  the  eriiption  appeai'ed.  The  nervous 
s^TnjDtoms  then  ceased,  and  the  disease  ran  a  jDarticularly  favourable  course. 

The  period  of  invasion  lasts  for  forty-eight  houi'S.  Dui'ing  all  this 
time  the  initial  symptoms  persist  and  the  temperature  continues  to  rise. 
The  j)p'exia  is  not  always  gTeat  at  this  stage.  A  boy,  aged  eleven  years, 
a  patient  in  the  East  London  Childi'ens'  Hospital,  sufiering  from  heart 
disease  and  pleurisy,  who  had  not  been  previously  feverish,  was  found  one 
morning  to  have  a  temperatui'e  of  101.6^.  The  next  morning  it  was  99°, 
and  in  the  evening  102°.  On  the  following  morning  (the  tlurd  day)  the 
thermometer  marked  102.2°,  and  the  emption  appeai-ed.  In  many  cases, 
however,  the  pyrexia  is  greater,  and  the  temperatui'e  may  reach  105°  or 
higher.  In  the  case  of  the  httle  gud  before  refeiTed  to  it  was  103.6°  on 
the  morning  of  the  second  day.  Occasionally  during  this  stage  a  roseo- 
lous  eruption,  very  Hke  the  rash  of  scarlatina,  aj)pears  upon  the  skim 
This  is  most  common  in  cases  of  modified  small-pox.  It  is  right  to  say 
that  the  symptoms  of  the  jDre-eruptive  stage  are  not  always  seen  ia  this 
marked  form.  Dr.  Twining  of  the  Homerton  Fever  Hospital  informs  me 
that  of  the  childi-en  who  are  admitted  into  that  institution  suffering  from 
variola,  many  have  complained  merely  of  malaise,  headache,  or  sickness  ; 
and  in  not  a  few  cases  the  first  symptom  noticed  was  the  rash  of  the 
disease. 

The  -eiiiptive  stage  begins  on  the  thii'd  day.     In  exceptional  cases — 


SMALL-POX — THE   EEUPTIVE   STAGE.  57 

usually  those  of  a  malignant  cliaracter — the  rash  may  appear  on  the  second 
day.  Occasionally  it  does  not  show  itself  until  the  fourth.  These  excep- 
tions are  found  in  all  the  eruptive  fevers.  The  special  small-pos  eruption 
hegins  as  small  red  papules  scattered  more  or  less  thickly  over  the  surface. 
They  are  first  noticed  on  the  chin,  nose,  or  forehead,  and  then  quickly 
spread  to  the  whole  face.  They  are  next  seen  on  the  wrists,  and  in  the 
course  of  the  following  twenty-four  or  forty-eight  hours  spread  gTadually 
to  the  chest,  the  arms,  the  trunk,  and  the  lower  limbs.  The  spots  are  not 
sprinkled  u-regularly  over  the  surface,  but  may  be  noticed  to  group  them- 
selves in  threes  and  fives,  often  arranged  in  a  semicu'cle.  Sometimes 
when  two  of  these  crescents  come  together,  they  may  by  then-  junction 
complete  the  circle.  The  spots  are  set  more  thickly  on  the  face  than  on 
the  body,  and  as  they  appear  earUest  in  this  situation,  they  run  through  all 
theu'  stages,  and  scab  earher  here  than  on  the  trunk  and  hmbs.  The 
papule  is  hard,  and  gives  to  the  finger  the  sensation,  of  a  small  shot  em- 
bedded in  the  skin.  All  are  not,  however,  of  equal  firmness.  Some  have 
much  more  of  a  shotty  character  than  others.  Between  the  papules  the 
skin  is  of  normal  colour  and  appearance  ;  but  if  the  spots  are  set  very 
closely  together,  there  may  be  a  general  redness  and  granular  look  of  the 
face  without  any  intervening  normal  tint  of  the  skin  being  visible. 

At  the  same  time  that  the  papules  appear  on  the  skin,  spots  may  be 
also  seen,  if  looked  for,  on  the  inside  of  the  cheeks  and  lips,  on  the  inside 
of  the  nose,  and  sometimes  even  on  the  conjunctivae.  At  first,  as  they 
cause  little  discomfort,  these  are  scarcely  complained  of ;  but  after  a  day 
or  two  they  produce  salivation,  and  jDain  in  swallowing,  and,  if  the  air- 
passages  are  similarly  affected,  hoarseness  and  cough.  There  is  also  some 
snuffling,  and  the  eyes  are  red  and  watery.  Later,  when  the  rash  is  ap- 
pearing on  the  lower  limbs,  the  mucous  membrane  of  the  vagina,  or 
urethra  and  prepuce,  also  become  the  seat  of  eruption. 

The  changes  which  occur  in  the  rash  are  as  follows  :  The  papule  en- 
larges, becoming  a  flat-topped  nodule,  and  in  the  course  of  the  second  or 
third  day  (fifth  or  sixth  of  the  disease)  changes  into  a  vesicle.  This 
change  takes  place,  as  has  been  said,  earlier  on  the  face  than  on  the  body 
or  limbs ;  and,  indeed,  while  the  pajjules  are  coming  out  on  the  lower 
extremities,  those  on  the  face  are  ah-eady  changing  into  vesicles.  The 
vesicle  is  broad,  flat-topped,  and  umbilicated.  Its  contents  are  opaque, 
and  at  first  whitish  in  colour  ;  but  by  the  sixth  day  (eighth  of  the  disease) 
have  become  distinctly  puitdent,  a  deep  red  areola  has  formed  rotmd  the 
pock,  and  the  subjacent  skin  is  swollen  by  inflammatory  effusion.  The 
spot  is  now  a  pustule  seated  on  a  thickened  base.  From  the  eighth  to 
the  eleventh  day  the  pock  enlarges  ;  and  the  union  of  neighbouring  areolae 
and  the  thickened  bases  of  the  pustules  produces  a  general  redness  and 
swelling  which  completely  obliterates  all  distinctive  character  in  the  feat- 
ures of  the  patient,  and  causes  a  distressing  tension  and  smarting  irrita- 
tion of  the  skin  which  is  gTcatly  complained  of.  There  may  be  also  extreme 
tenderness,  so  that  the  slightest  touch  is  painful.  The  eyes  are  often  closed 
by  the  swelling,  and  the  hds  are  glued  together  by  the  vitiated  secretions 
from  the  Meibomian  glands  ;  the  nose  is  stopped  up  ;  the  secretion  of 
saliva  is  profuse  ;  and  swallowing  is  very  difficult  and  painful.  The  voice, 
too,  is  hoarse  and  the  cough  distressing.  Often  the  eyes  are  inflamed, 
painful,  and  very  sensitive  to  hght.  The  process  of  maturing  of  the 
pustules  (stage  of  maturation)  lasts  from  the  sixth  to  the  ninth  day  (eighth 
to  the  eleventh  of  the  disease)  on  the  face  ;  on  the  lower  limbs  it  begins 
and  ends  a  day  or  two  later.      Consequently,  the  vaginal  and  urethi-al 


58  DISEASE  IN"   CHILDEET^. 

rashes  and  tlie  distress  tliey  produce  are  at  their  height  when  the  faucial 
and  laryngeal  mucous  membranes  have  begun  to  improve.  On  these  and 
the  other  mucous  surfaces  the  eruption  does  not  pass  beyond  the  vesicular 
stage,  but  is  accompanied  by  considerable  redness  and  swelling  of  the 
membrane.  "While  the  pustules  are  maturing  on  the  skin,  the  suppurat- 
ing sj^ots  give  out  a  peculiar  and  unpleasant  odor,  which  is,  however,  char- 
acteristic of  the  disease. 

The  eruptive  stage  lasts  about  eight  days — from  the  third  to  the 
eleventh  of  the  illness.  The  appearance  of  the  rash  is  usually  the  signal 
for  a  remission  in  the  fever,  and  in  the  symptoms  of  general  constitutional 
disturbance  ;  but  there  is  seldom  a  notable  fall  in  the  temperature  until 
the  eruption  is  fully  out.  If  the  pyrexia  remain  high  after  the  papular 
stage  is  completed,  the  disease  is  severe  and  unmodified,  or  some  compli- 
cation is  present.  In  confluent  small-pox  the  remission  is  very  imperfect 
and  transient,  the  reduction  of  temperature  is  inconsiderable  ;  and  whereas 
in  a  mild  discrete  case  the  patient  feels  almost  well  at  this  time,  in  the 
severer  form  of  the  disease  the  alleviation  to  the  distress  is  much  less 
complete,  and  even  at  this  early  stage  of  the  illness  photophobia,  saliva- 
tion, ]3ain  in  deglutition,  and  hoarse  cough  may  be  the  source  of  great 
discomfort.  In  an  ordinary  case  of  discrete  small-pox  when  the  eruption 
is  fully  out,  the  temperature,  although  still  above  the  normal  level,  is  com- 
paratively little  raised ;  nervous  symptoms  are  no  longer  noticed  ;  and 
except  for  the  local  inconvenience  of  the  state  of  the  skin,  the  condition  of 
the  patient  is  greatly  improved. 

When  the  pustular  stage  is  reached  and  the  process  of  maturation  be- 
igins  (about  the  sixth  day  of  the  rash,  eighth  or  ninth  of  the  disease),  the 
temj^erature  rises  again,  and  what  is  called  "  the  secondary  fever  "  begins. 
The  intensity  of  this  later  pyrexia  varies  according  to  the  severity  of  the 
attack.  In  mild  cases  it  may  be  slight  or  even  absent ;  but  m  severe  cases, 
especially  in  the  confluent  form  of  the  fever,  the  temperature  rises  to  a 
higher  level,  perhaps,  than  in  the  earlier  stage  ;  the  child  is  stupid  or  de- 
lirious, and  often  wakeful  at  night ;  his  tongue  is  furred  and  often  dry  ;  his 
pulse  gets  quick  and  feeble  ;  his  weakness  is  great ;  and  tremors,  subsultus 
tendinum,  with  other  symptoms  of  prostration,  may  be  noticed.  In  not  a 
few  cases  the  disease  has  ended  in  death  before  the  period  of  secondary 
fever  is  reached.  In  the  severe  cases,  if  the  patient  do  not  die  at  this 
time  from  the  violence  of  the  disease,  he  is  very  apt  to  succumb  to  an  in- 
flammatory complication. 

The  secondary  fever  lasts  until  the  maturation  of  the  pustules  is  com- 
pleted on  the  eleventh  or  twelfth  day  of  the  iUness.  The  disease  then  en- 
ters into  its  latest  period,  that  of  desiccation  and  decline.  In  the  course 
of  two  or  three  days  the  pustules  discharge  their  contents ;  the  redness 
and  swelling  of  the  skin  subside  ;  the  odor  from  the  child's  body  becomes 
extremely  ofl:ensive ;  and  yellowish-brown,  thick  scabs  form  from  caking 
of  the  purulent  secretion.  Nearly  at  the  same  time — unless  some  febrile 
complication  arise — the  pyrexia  begins  to  subside  and  the  tongue  to  clean  ; 
the  painful  symptoms  connected  with  the  mucous  membranes  disappear  in 
the  order  in  which  they  occurred ;  the  pulse  slackens  and  the  appetite  im- 
proves. The  falUng  of  the  crusts  is  accompanied  by  some  itching  of  the 
skin.  It  takes  place  earlier  in  some  parts  than  in  others,  and  is  delayed  in 
proportion  to  the  amount  of  ulceration  which  is  present  in  the  cutis.  If 
this  be  great,  the  scabs  become  very  thick  and  horny,  and  remain  attached 
for  a  long  time.  Sometimes  successive  crops  of  scab  are  thrown  off  before 
the  underlying  surface  has  become  healthy.     The  size  of  the  fallen  crusts 


SMALL-POX — COMPLICATIONS.  59 

is  also  subject  to  variety.  If  the  pustules  have  been  thickly  set,  the  edges 
of  the  neighbouring  scabs  may  unite,  so  that  large  pieces  of  dark  brown, 
horny  crust  become  detached  at  the  same  time.  The  separation  of  the 
scabs  is  often  very  slovy'  on  the  scalp  in  children  ;  and  often  new  crusts 
continue  to  form  after  old  ones  have  been  removed  with  wearisome  persist- 
ence. "When  the  crusts  have  all  fallen,  the  surface  is  left  mottled  with 
slightly  elevated  red  spots,  which  eventually  either  disappear  leaving  no 
trace,  or,  if  there  has  been  ulceration,  change  into  depressed  white  deep 
scars  vnth  inverted  edges  and  an  irregular  floor. 

Complications. — In  severe  cases,  even  if  the  child  survive  until  the  pe- 
riod of  the  secondary  fever,  he  is  very  apt  at  that  time  to  be  carried  off 
by  some  one  of  the  many  complications  which  are  liable  to  come  on  in  the 
third  or  fourth  week  of  the  illness.  The  severe  forms  of  small-pox,  es^DC- 
cially  the  confluent  variety,  are  most  commonly  attended  by  these  acci- 
dents ;  but  they  may  also  follow  the  milder  forms  of  the  disease. 

Boils  are  very  frequently  seen ;  and  the  intense  inflammation  of  the 
cutis  which  occurs  in  the  severer  attacks  may  pass  into  partial  mortification 
of  the  tissues.  Spots  of  gangrene  are  thus  formed  in  the  skin,  and  the 
same  thing  may  be  observed  in  the  genitals.  If  a  scrofulous  child  who 
suffers  from  vaginitis  be  attacked  by  sniall-pos,  there  is  gTeat  danger  lest 
gangrene  of  the  vulva  supervene.  Such  cases,  it  need  not  be  said,  are 
very  dangerous. 

Abscesses  and  acute  cellulitis  may  occur.  Deep-seated  collections  of 
matter  often  form  and  may  reach  a  considerable  size.  They  are  slow  to 
heal.     Sometimes  the  joints  are  the  seat  of  suppuration. 

Erysipelas  and  pycemia  are  common  in  small-pox  hospitals — less  com- 
mon in  private  houses,  although  they  may  be  met  vnth  anywhere  when  the 
disease  is  confluent  or  very  severe.  The  latter  of  the  two  sometimes  suc- 
ceeds to  the  former  and  is  very  fatal. 

Otitis  with  suppuration  in  the  middle  ear  is  a  not  uncommon  complica- 
tion. The  results  which  may  follow  from  this  distressing  affliction  are 
described  elsewhere. 

In  all  bad  cases  of  small-pox  there  is  conjunctivitis,  which  may  come 
on  as  early  as  the  fifth  or  sixth  day  of  the  eruption.  If  swelling  prevents 
the  lids  from  being  opened,  conjunctivitis  may  be  suspected  if  the  child 
complain  of  pain  in  the  eyeball,  increased  by  movement  of  the  eye, 
and  of  a  feehng  of  dirt  beneath  the  lid.  In  very  rare  instances  we 
meet  with  a  development  of  smaU  pustules  on  the  mucous  membrane  of 
the  eye  ;  but  slight  ophthalmia  of  this  kind  as  a  rule  is  easily  overcome. 
The  severe  inflammation  which  leads  to  ulceration  of  the  cornea  and  de- 
struction of  the  eyeball  sets  in  about  the  beginning  of  the  third  week  (on 
the  fourteenth  day,  according  to  Mr.  Marson).  An  ulcer  appears  on  the 
margin  of  the  cornea,  sometim.es  on  both  sides  of  the  cornea  at  the  same 
time.  The  various  layers  are  quickly  penetrated  ;  the  aqueous  hvmaour  es- 
capes ;  and  often  the  lens  and  vitreous  humour  are  discharged.  The  process 
is  generally  very  rapid,  and  may  be  accompanied  by  no  pain  to  the  child. 
Sometimes,  instead  of  ulceration,  general  sloughing  of  the  eyeball  may  occur. 

To  some  form  of  chest  affection  many  deaths  in  small-pox  are  owing. 
Pleurisy  is  common  and  very  fatal.  Pneumonia  may  begin  insidiously, 
and  is  also  a  very  serious  complication.  Bronchitis  is  sometimes  a  cause 
of  death  ;  and,  according  to  EiUiet  and  Barthez,  pulmonary  oedema  is  occa- 
sionally met  with.  Besides  these,  peri-  and  endo-carditis  may  supeiwene, 
and  it  is  stated  on  the  authority  of  Desnos  and  Huchard  that  acute  fatty 
degeneration  of  the  walls  of  the  heart  may  be  a  cause  of  sudden  death. 


60  DISEASE   IN"   CHILDREN". 

The  laryngeal  symptoms  during  the  period  of  secondary  fever  may  be 
complicated  by  oedema  of  the  larynx.  This,  however,  is  seldom  seen 
except  in  cases  of  confluent  small-pox.  In  other  instances  a  severe  laryn- 
gitis may  be  set  up,  leading  to  ulceration  of  mucous  membrane,  perichon- 
dritis, and  necrosis  of  cartilage  with  consequent  chronic  aphonia.  Laryn- 
gitis may  be  one  of  the  earliest  complications,  and  is  sometimes  seen  on  the 
tenth  or  eleventh  day. 

In  the  case  of  any  of  these  complications  the  fever  is  high  and  the  child, 
who  is  barely  entering  upon  convalescence  after  an  exhausting  disease,  is 
in  a  state  of  great  weakness,  which  is  instantly  aggTavated  by  the  presence 
of  the  intercui-rent  lesion.  So  that,  if  the  patient  do  not  succun;ib  to  this 
new  danger,  his  illness  is  seriously  protracted  and  convalescence  propor- 
tionately delayed. 

Varieties. — Many  varieties  of  small-pox  have  been  described ;  but  for 
practical  purposes  it  will  be  sufficient  to  remember  the  special  forms  of 
Discrete,  Confluent,  and  Mahgnant  small-pox,  and  the  modified  form  found 
in  efficiently  vaccinated  persons  which  is  called  varioloid. 

In  the  discrete  variety  the  sj)ots  are  separated  from  one  another  by 
healthy  skin  of  normal  tint.  The  general  symptoms  are  usually  milder, 
and  the  fever  less  high,  especially  the  secondary  pyrexia,  which  is  much 
less  severe.  Still,  even  in  this  form  serious  complications  may  arise,  and 
when  death  occurs,  it  is  usually  owing — unless  the  patient  be  a  young  in- 
fant— to  one  of  these  secondary  lesions. 

The  confiuent  form  is  attended  by  a  very  high  mortahty.  From 
the  records  of  the  London  Fever  Hospital  it  appears  that  of  those  at- 
tacked by  this  variety  fifty  per  cent.  die.  In  children  probably  the 
proportion  of  deaths  would  be  much  greater.  The  danger  consists  not 
onty  in  the  severity  of  the  eruption,  but  also  in  the  intensity  of  the  general 
symptoms.  The  initial  fever  is  very  violent,  and  is  often  accompanied  by 
high  delirium  ;  there  is  httle  remission  in  the  pja-exia  when  the  develop- 
ment of  the  rash  is  completed  ;  tremors  and  signs  of  profound  nervous  de- 
pression come  on  early  ;  the  swelling  and  inflammation  of  the  mucous 
membranes  produce  great  distress  ;  and  the  secondary  fever  is  very  vio- 
lent. If  the  child  survive  to  the  third  week,  which  rarely  happens,  a  seri- 
ous complication  usually  occurs,  and  this  in  his  exhausted  state  proves 
rapidly  fatal. 

These  cases,  on  account  of  their  severity  and  fatality  in  young  subjects, 
might  be  justly  described  as  malignant.  The  term  is,  however,  usually 
confined  to  cases  in  which  the  nervous  symptoms  are  overwhelming,  and 
the  child  dies  rapidly  from  blood-poisoning  in  a  state  of  j)rofound  depres- 
sion and  coma  ;  or  to  cases  where  the  disease  assumes  a  ha;morrhagic 
character.  In  this  hsemorrhagic  form  bleeding  occurs  from  all  the  mucous 
membranes — the  nose,  the  mouth,  the  air-passages,  and  the  bowels.  The 
urine  is  smoky  or  red  with  blood  ;  the  eruption  is  dark,  and  mixed  up  with 
petechiee  or  larger  subcutaneous  extravasations  ;  and  the  fluid  in  the  vesicles 
is  tinged  with  blood.  The  general  symptoms  are  severe,  the  prostration 
great,  and  death  takes  place  after  a  few  days.  My  fi'iend,  Dr.  Twining, 
has  described  to  me  a  variety  of  the  mahgnant  form  of  small- pox  which  has 
often  come  under  his  notice  at  the  Homerton  Fever  Hospital.  In  this  the 
child  appears  overwhelmed  by  the  violence  of  the  disease.  He  lies  in  a 
state  of  stupor,  and  has  no  true  variolous  rash  nor  any  of  the  ordinary 
symptoms  of  the  illness.  On  inspection  of  the  skin  a  number  of  deep 
purjDle,  almost  black,  spots  are  seen.  These  are  weU  defined,  and  are  more 
or  less  circular  in  shape.     They  vary  in  size  from  a  rape  to  a  millet  seed, 


SMALL-POX — VAEIETIES — DIAGT^OSIS.  61 

and  are  twenty  or  thirty  in  number.  Mixed  up  with  them  are  larger 
patches  of  subcutaneous  extravasation,  Hke  bruises.  These  patients  have 
a  very  offensive  smell,  as  if  putrefaction  had  begun  before  death,  and  sur- 
vive but  a  few  hours. 

Varioloid,  the  modified  form  of  the  disease,  is  usually  a  mild  com- 
plaint. The  early  symptoms  are  the  same  as  in  true  small-pox,  and  may 
.even  be  of  some  severity.  A  child  may  have  high  fever,  much  pain  in 
the  back,  repeated  vomiting,  and  be  convulsed  ;  but  the  after-course  of 
the  disease  is  usually  benign,  and  in  particular  the  secondary  fever  is  slight 
or  completely  absent.  Often,  the  rash  is  preceded  by  a  roseolous  eruption. 
The  proper  rash  of  varioloid,  which  comes  out  at  the  usual  time,  is  in  most 
cases  comparatively  thinly  scattered  over  the  sm-face,  and  the  spots  are 
very  rarely  set  sufficiently  closely  to  be  confluent,  even  on  the  face.  As  in 
variola,  the  mucous  membranes  are  aflected  ;  and  salivation,  difiicult  deglu- 
tition, snuffling,  hoarseness,  and  cough  are  common  symptoms.  The  sjoots 
run  through  their  stages  more  quickly  than  in  the  unmodified  form,  and 
the  stage  of  desiccation  usually  begins  on  the  fifth  or  sixth  day  of  the  erup- 
tion. The  stage  of  maturation  is  also  less  severe  ;  there  is  less  swelling 
and  redness  of  the  skin  ;  and  pyrexia  is  slight  or  absent.  Generally  the 
pustules,  instead  of  rupturing  and  discharging  their  contents,  dry  up,  so 
that  the  pock  gradually  changes  into  a  thin  brown  scab,  wliich  falls  off  in  a 
few  days.  There  is  besides  little  or  no  ulceration  of  the  skin,  and  conse- 
quently no  pitting  is  left  after  the  subsidence  of  the  disease,  except  here 
and  there  where  the  inflammation  had  proceeded  farther  than  usual.  Lastly, 
in  varioloid  complications  are  rare,  and  the  disease  is  usually  at  an  end  in 
a  fortnight. 

Diagnosis. — Before  the  eruption  appears  the  diagnosis  of  small-jDox  is 
difficult  in  children,  for  fever  and  vomiting  usher  in  many  of  their  acute 
diseases,  and  pain  in  the  back  is  not  always  complained  of.  In  young 
children  the  existence  of  the  spinal  pain  can  seldom  be  ascertained  ;  but  if 
a  child,  in  addition  to  vomiting  and  fever,  loses  control  over  his  sphincters, 
we  may  suspect  small-pox,  for  such  incontinence  is  not  a  common  symjotom, 
and  points  to  some  special  condition  not  present  at  the  onset  of  an  ordinary 
acute  illness.  In  small-pox  it  may  be  the  consequence  of  the  spinal  irri- 
tation. 

When  the  eruption  flrst  appears  on  the  face  it  is  often  mistaken  for 
measles.  The  colour  is  very  similar  ;  and  the  early  papules  may  be  easily 
confounded  with  that  form  of  measles  rash  in  which  the  spots  are  more 
than  usually  elevated  above  the  surface.  On  closer  inspection,  however, 
differences  will  be  noticed.  The  measles  spot  is  much  less  raised  than  the 
small-pox  papule,  and  is  not  hard  and  resisting  to  the  finger.  Moreover, 
in  measles  the  cough,  coryza,  and  lachrymation  are  significant  symptoms, 
and  are  quite  absent  in  the  early  period  of  variola.  The  temperature,  too, 
is  less  elevated  in  measles  during  the  stage  of  invasion  than  in  small-pox. 
In  measles  it  is  usually  between  102.5°  and  104°,  while  in  variola  it  is  often 
between  105°  and  106°.  After  a  day  or  two  the  change  of  the  papule  into 
a  vesicle  removes  any  doubts  that  may  have  been  entertained  as  to  the 
nature  of  the  illness. 

The  roseolous  rash  which  sometimes  precedes  the  papular  eruption 
may  be  mistaken  for  scarlatina.  It  is  distinguished  from  it  by  noting  its 
less  complete  diffusion  over  the  surface,  its  brighter  tint,  and  more  mottled 
character.  Moreover,  according  to  M.  See,  in  cases  of  small-pox,  when  the 
roseolous  eruption  is  present,  the  variolous  papule  has  already  begun  to 
appear,  and  may  be  discovered  by  careful  examination. 


62  DISEASE  IIST   CHILDEElSr. 

The  remission  of  the  fever,  which  often  takes  place  when  the  papular 
eruption  is  completed,  cannot  be  relied  upon  for  diagnosis,  as  it  is  very 
uncertain.  In  the  boy  whose  case  was  referred  to  at  the  beginning  of 
this  chapter  there  was  no  remission  of  the  fever  at  the  early  period  of  the 
eruptive  stage.  On  the  contrary,  the  temperature  rose  still  higher,  and 
when  the  patient  was  sent  away  to  the  small-pox  hospital  on  the  third  day 
of  the  rash,  the  spots  being  then  vesicular,  his  temperature  (at  8  a.m.)  was. 
103.4°. 

Varicella  may  be  readily  mistaken  for  modified  small-pox.  The  differ- 
ences between  the  two  diseases  are  described  elsewhere. 

Prognosis. — The  mortality  from  small-pox  in  childhood  is  very  high  up 
to  the  age  of  ten  years.  Infants  usually  succumb  to  the  disease  even  in 
the  discrete  form.  The  previous  health  of  the  child  is  an  important  item 
in  estimating  his  chances  of  recovery,  for  weakly  children  have  small  pros- 
pect of  passing  safely  through  so  formidable  a  trial.  Little  information 
can  be  gained  from  the  severity'-  of  the  initial  stage,  for  violent  convulsions 
may  usher  in  a  benign  form  of  the  disease.  Remission  of  the  fever  and 
constitutional  symptoms  at  the  beginning  of  the  eruptive  stage,  scantiness 
of  the  rash,  normal  development  of  the  spots,  and  absence  of  subcutaneous 
hsemorrhages,  are  favourable  symptoms  ;  but  even  in  these  cases  a  serious 
complication  may  arise  during  the  third  stage  and  carry  off  the  patient. 

Of  special  symptoms,  profuseness  of  salivation  is  not  an  unfavourable 
sign,  although  it  occasions  much  discomfort.  Mr.  Marson  even  regards  it 
as  of  auspicious  omen,  esjDecially  if  combined  vdth  much  swelling  of  the  face 
and  marked  tenderness  of  the  skin.  Bleeding  from  a  mucous  surface,  if 
limited  to  one  tract  of  that  membrane,  is  not,  according  to  Dr.  CoUie,  to  be 
viewed  with  apprehension  ;  but  if  more  than  one  tract  is  a  source  of 
ha?morrhage,  the  prognosis  is  very  unfavourable.  Hematuria  is  not  neces- 
sarily dangerous  ;  but  haemorrhage  into  the  skin,  if  anything  more  than  a 
few  scattei'ed  petechise  can  be  seen,  is  of  very  serious  import. 

Destructive  ulceration  of  the  eyes  may  be  exjjected  in  cases  of  the  con- 
fluent form  of  the  disease  when  tlie  secondary  fever  is  high  and  the  skin 
is  very  hot  and  dry.  If,  in  such  a  case,  the  eyes  do  not  suffer,  some  other 
serious  comphcation  is  certain  to  occur,  according  to  ]Mi\  Marson.  The 
same  authority  asserts  that  if  an  ulcer  be  found  at  the  same  time  on  each 
side  of  the  cornea,  that  eye  will  be  entirely  destroyed. 

Treatment. — In  varioloid  and  the  milder  cases  of  discrete  smaU-pox  the 
child  merely  requires  to  be  kejDt  in  bed  in  a  large  well-ventilated  room, 
and  to  be  fed  with  such  articles  of  diet  as  are  suitable  to  his  age  and  de- 
gree of  pyrexia.  ^Tiile  the  fever  is  high,  he  should  take  nothing  but  milk 
and  broth  ;  but  when  the  pyrexia  subsides,  he  may  take  fish  or  once  cooked 
meat,  hght  puddings,  etc.  His  whole  body  should  be  sponged  daily  with 
tepid  water,  and  if  there  is  much  heat  of  skin,  this  process  may  be  repeated 
several  times  in  the  twenty-four  hours.  He  may  be  allowed  to  drink  freely 
of  pure  cold  water,  and  his  bed  and  body  linen  should  be  changed  every 
day.  No  medicine  will  be  requu-ed  unless  constipation  be  present,  when 
a  moderate  dose  of  castor-oil  is  indicated.  As  in  scarlatina,  the  room 
should  be  cleared  of  all  carpets,  rugs,  ciu-tains,  and  other  wooUen  fabrics 
not  absolutely  indispensable.  Open  windows,  whatever  be  the  season  of 
the  year,  are  insisted  on  by  Dr.  Collie. 

The  severer  forms  of  the  disease,  and  especially  the  confluent  variety, 
require  very  careful  treatment.  The  diet  should  be  liberal,  given  in  such 
form  as  the  child  can  digest,  and  in  quantity  suitable  to  his  power  of  as- 
similation.    Milk,  strong  beef-tea,  essence  of   meat,  yolks  of  eggs,  hght 


SMALL-POX — TEEATMENT.  63 

puddings,  and  jelly  can  be  given  frequently  and  in  small  quantities  at  a 
time.  Stimiilants,  such  as  brandy  and  the  brandy-and-egg  mixture,  will 
also  be  needed  whenever  signs  of  failure  of  strength  are  observed.  It  is 
best,  however,  to  withhold  stimulants  during  the  earher  period  of  the  ill- 
ness, unless  they  are  imperatively  required,  for  they  will  certainly  be 
wanted  at  the  end  of  the  second  or  beginning  of  the  third  week,  when  com- 
plications generally  appear. 

If  the  patient  be  restless  at  night  and  wakeful,  a  little  chlorodine  may 
be  given  cautiously ;  but  we  must  be  careful  in  giving  narcotics,  partly  on 
account  of  the  easily  depressed  condition  of  the  patient,  partly  because 
the  air-passages  become  readily  choked  by  the  abundant  mucous  and  sali- 
vary secretion. 

The  treatment  of  the  skin  eruption  is  an  important  matter ;  for  in 
small-pox,  uulike  the  other  eruptive  fevers,  the  dermatitis  which  accompa- 
nies the  maturation  of  the  pustules  may  produce  severe  local  injury  as  well 
as  marked  constitutional  disturbance.  Very  many  different  methods  have 
been  recommended  and  adopted  for  checking  the  ulcerative  process  and 
preventing  pitting  of  the  skin  ;  but  none  of  these  can  be  said  to  be  success- 
ful. The  application  of  salves  of  various  kinds  appear  to  be  useful,  but 
rather  through  the  oil  or  fat  they  contain  than  through  the  chemical  ingre- 
dient which  was  supposed  to  give  them  their  value.  Dr.  CoUie  pronounces 
against  distressing  the  patient  by  efforts  in  this  direction,  which  are  cer- 
tain to  prove  ineffectual,  and  merely  recommends  the  use  of  olive-oil  to 
the  skin.  A  thirtieth  part  of  carbolic  acid  increases  the  value  of  this  appli- 
cation. German  writers  speak  highly  of  cold  compresses  to  the  face  and 
.  hands,  and  to  any  other  part  where  the  eruption  is  copious.  They  state 
that  the  apphcation  diminishes  pain,  heat,  and  redness,  and  contributes 
greatly  to  the  comfort  of  the  patient. 

The  sore  throat  is  best  treated  by  barley-water  and  other  mucilaginous 
drinks.  A  draught  containing  perchloride  of  iron  and  glycerine,  taken 
three  times  a  day,  is  often  of  service. 

At  the  end  of  the  second  week  we  must  be  on  the  watch  for  complica- 
tions. Laryngitis  is  often  the  first  to  appear,  and  indeed  this  interciuTent 
disorder  may  begin  as  early  as  the  tenth  day.  When  this  complication  oc- 
curs, the  room  must  be  kept  warm  (a  temperature  of  70°  is  sufficient)  ;  the 
cot  must  be  surrounded  with  an  atmosphere  of  steam  from  some  one  of  the 
many  apparatus  constructed  for  this  purpose  ;  and  the  throat  should  be 
enveloped  in  hot  linseed-meal  poultices.  Stimulants  must  be  given  as 
seem  desirable.  If  signs  of  suffocation  are  noticed,  tracheotomy  should  be 
performed  at  once.  In  cases  of  oedema  of  the  glottis,  where  life  is  in  the 
greatest  danger,  and  immediate  measures  have  to  be  taken  to  avert  a  fatal 
issue,  much  benefit  may  be  derived  from  rapid  vesication.  This  is  best 
done  by  means  of  boiling  water.  Dr.  Owen  Rees  directs  that  the  corner 
of  a  towel  should  be  soaked  in  water  as  this  boUs  on  the  fire,  so  as  to  ac- 
quire the  full  temperature,  and  that  it  should  be  then  applied  rapidly  to 
the  region  of  the  throat.  Before  doing  so,  the  surrounding  parts  which  it 
is  not  wished  to  blister  must  be  covered  with  thick  cloths. 

Diarrhoea,  if  it  be  ti'oublesome,  must  be  treated  with  a  small  dose  of 
castor-oil,  followed  up,  if  necessary,  by  a  draught  containing  dilute  sul- 
phuric acid  and  a  drop  or  two  of  tincture  of  opium.  An  enema  of  starch 
with  five  or  ten  drops  of  laudanum  is  also  useful.  If  the  diarrhoea  resist 
this  treatment  and  become  exhausting,  nitrate  of  silver  or  gallic  acid  and 
opium  must  be  resorted  to. 

The  various  forms  of  chest  affection  must  be  treated  upon  general  prin- 


64  DISEASE  IN   CHILDREN. 

ciples.  They  axe  excessively  dangerotis.  As  tlie  patient  is  usually  by  this 
time  in  a  state  of  great  exhaustion,  stimulants  must  be  given  hberally  ;  and 
strong  beef-essence  and  other  forms  of  food  containing  much  nouiishment 
in  small  bulk  must  be  administered  in  small  quantities  at  a  time. 

If  an  ulcer  a^^pear  upon  the  cornea,  it  should  be  touched  v,ith  a  solution 
of  nitrate  of  silver  (gi*.  xx.  to  the  ounce),  and  afterwards  some  ohve-oil  should 
be  di-opped  into  the  eye.  A  bhster  to  the  temple  is  also  of  sei-vice.  The 
conjunctivitis  may  be  treated  in  mild  cases  by  a  solution  of  sulphate  of  zinc 
(gT.  iij.  to  the  ounce),  di'opped  into  the  eye  thi-ee  or  four  times  a  day  ;  or  a 
solution  of  the  nitrate  of  silver  (gr.  j.  to  the  ounce)  may  be  used.  If  the  case 
is  severe,  vdth  much  muco-pui'ulent  discharge,  3Ii-.  Makuna  recommends 
the  stronger  solution  of  the  nitrate  to  be  drojDped  into  the  eye  once  a  day. 
The  lids  may  be  prevented  fi'om  adhering  by  bathing  fi-equently  with  warm 
water,  and  then  placing  a  drop  of  castor-oil  between  them. 

Abscesses  must  be  opened  early.  Any  sign  of  suppuration  is  a  signal 
for  stimulants,  and  for  quinine  with  or  without  perchloride  of  iron. 

If  h;i?morrhage  occur,  the  patient  must  be  kept  perfectly  quiet,  and  stim- 
ulants must  be  given  as  requii'ed. 

In  all  cases  where  the  skin  eraption  is  profuse,  cleanhness  is  of  the  ut- 
most importance.  Dr.  Collie  especially  dii-ects  the  removal  of  all  crusts 
about  the  nostiils  and  Ups  as  they  form,  for  they  poison  the  air  as  it  enters 
the  body  of  the  patient.  He  also  insists  upon  the  early  removal  of  all 
scabs  under  which  pus  is  forming,  and  recommends  that  the  patient  be 
bathed  daily  in  a  bath  medicated  T^ith  carbohc  acid.  He  also  points  out 
the  necessity  of  frequent  changing  of  the  body  linen.  If,  as  often  happens, 
the  child's  head  is  slow  in  recovering,  the  scabs  must  be  removed  by  poul- 
ticing, and  zinc  ointment  must  be  apphed,  or  the  following  : 

^ .  Liq.  plumbi  subacetatis 5  ]• 

Zinci   oxydi 3  j- 

Vaseline 3  ^j- 

M. 

Cod-liver  oil  and  ii'on  ai-e  also  indicated. 

In  the  malignant  f  oi-m  of  the  disease  no  treatment  is  successful,  and  the 
patient  invariably  dies. 


CHAPTER  VII. 

MUMPS. 

Mumps,  or  Parotiditis,  is  one  of  the  milder  infectious  disorders  of  child- 
hood. It  is  rare  in  infancy,  and  cannot  be  said  to  be  common  before  the 
fourth  or  fifth  year.  Again,  after  puberty  the  liability  to  the  disease  di- 
minishes. It  seldom  occurs  a  second  time  in  the  same  subject.  Mumps 
is  usually  epidemic,  and  is  especially  common  in  the  spring-  of  the  year. 
Its  infectiousness  is  extreme,  so  that  if  the  complaint  break  out  in  a 
school,  or  other  institution  where  young  people  are  congregated  together, 
few  are  Hkely  to  escape.  The  virus  is  suj^posed  to  be  conveyed  in  the 
breath.  The  duration  of  the  illness  is  from  a  week  to  ten,  twelve,  or  foui-- 
teen  days.  There  is,  besides,  a  period  of  incubation  which  has  been 
variously  estimated  at  from  one  to  three  weeks. 

Morbid  Anatomy. — The  disorder  consists  in  an  inflammation  of  the  ducts 
of  the  parotid  and  other  salivary  glands,  with  infiltration  of  the  cellular 
tissue  of  the  glands.  Exudation  also  invades  the  subcutaneous  tissue  for 
some  distance  around,  so  that  very  widespread  swelling  may  be  the  con- 
sequence. The  diseased  action  does  not  go  on  to  suppuration,  but  ter- 
minates in  resolution  in  the  course  of  a  few  days. 

Symptoms. — After  a  period  of  incubation  which,  according  to  Dr. 
Dukes,  varies  from  sixteen  to  twenty-five  days,  the  earUest  signs  of  the  dis- 
order are  noticed.  The  first  symptom  is  fever,  which  usually  precedes  by 
some  hours  any  sign  of  local  discomfort.  The  temperature  is  generally 
high,  rising  sometimes  to  103°,  and,  as  is  often  the  case  with  children,  the 
pyrexia  is  apt  to  be  accompanied  by  headache  and  vomiting.  Swelling  of 
the  parotid  gland  may  occur  at  the  same  time  as  the  fever,  or  may  even 
precede  it.  In  any  case  attention  is  soon  attracted  to  the  face.  Aching 
and  tenderness  are  complained  of,  situated  immediately  below  the  ear„ 
and  behind  the  ascending  ramus  of  the  jawbone ;  and  on  inspection  the 
normal  i  depression  between  the  face  and  the  neck  is  found  to  have  disap- 
peared. The  sweUing  strikes  forward  into  the  face,  and  backward  and 
downward  into  the  neck,  so  that  when  fully  developed  it  covers  the  whole  of 
the  parotid  region.  If,  as  often  happens,  the  inflammation  extends  to  the 
submaxillary  glands,  and  attacks  both  sides,  the  famihar  face  is  curiously 
disfigured,  and  is  scarcely  recognizable  by  the  friends.  It  is  enormously 
widened  at  the  level  of  the  nose  and  lip,  and  the  chin  may  almost  dis- 
appear in  the  swelling  of  the  neck.  The  swelling  is  very  tense  and  elastic, 
and  is  extremely  sensitive  to  pressure.  The  skin  over  it  is  either  pale  or 
is  suffused  with  a  rosy -red  blush.  The  full  develo^Dment  of  the  swelling- 
occupies  from  three  to  six  days  ;  then,  after  remaining  itnaltered  for  one 
or  two  days  longer,  it  begins  to  subside,  and  by  the  tenth  or  twelfth  day 
from  the  beginning  of  the  disorder  all  fulness  has  disappeared.  During 
the  whole  of  this  time  the  aching  continues,  and  is  greatly  intensified  by- 
movement  of  the  jaw ;  so  that  mastication  becomes  impossible,  speech  is 
5 


66  DISEASE   IN   CHILDEElSr. 

hampered,  and  even  swallowing  is  difficult  and  painful.  One  consequence 
of  this  is  that  saHva  tends  to  accumulate  in  the  mouth,  and  is  a  cause  of 
much  discomfort.  Fortunately,  however,  its  secretion  is  seldom  greater 
than  natural. 

While  the  disease  is  in  progress  the  fever  remains  high.  When  the 
swelling  has  reached  its  full  development,  the  temperatiu'e  falls,  suddenly 
or  gradually,  and  during  the  process  of  resolution  the  heat  of  the  body  is 
natural.  The  disease  seldom  attacks  the  two  sides  of  the  face  quite  si- 
multaneously. One  side  generally  jDrecedes  the  other  by  some  hours  or 
days.  In  rare  cases  the  inflammation  remains  Hmited  to  the  gland  first 
attacked. 

Although  the  parotid  glands  are  j)rimarily  and  principally  affected  in 
the  large  majority  of  cases,  this  is  not  the  invariable  rule.  Sometimes  the 
inflammation  is  localized  in  the  submaxillary  glands,  and  the  parotids  suffer 
little  if  at  all.  Dr.  Penzoldt,  of  Erlangen,  in  an  epidemic  of  undoubted 
mumps  occui-ring  in  that  town,  noted  some  cases  in  which  the  swelling  of 
the  parotids  was  so  slight  as  to  be  scarcely  observable,  while  the  sub- 
maxillary glands  were  considerably  enlarged  and  very  painful.  In  one 
case  there  was  in  addition  swelling  and  redness  of  the  tonsils. 

One  of  the  most  ciirious  features  of  this  disorder  consist  in  the  metas- 
tases which  occasionally  occur.  As  the  inflammation  subsides,  or  even  a 
day  or  two  after  the  swelling  has  disappeared,  a  similar  condition  develops 
itself  in  a  distant  part — the  testicle,  in  the  case  of  a  boy  ;  the  breast,  if  the 
23atient  be  a  girl.  These  complications  are  accompanied  by  fever  and  gen- 
eral poorliness,  but  subside  in  the  course  of  a  few  days.  In  rare  cases 
orchitis  has  been  known  to  pi'ecede  the  affection  of  the  parotid  gland. 
Thus,  a  young  gentleman  described  to  me  how  he  had  had  an  attack  of 
orchitis,  accompanied  by  severe  pain  but  a  normal  temperature.  At  this 
time  there  was  absolutely  no  symptom  connected  with  the  face.  Sixteen 
hours  afterwards,  however,  slight  swelling  and  tenderness  of  the  parotid 
gland  began  to  be  noticed,  and  the  temperature  was  found  to  be  100.6°. 
As  the  mumj)S  subsided,  the  second  testicle  became  inflamed.  In  this 
attack  the  temperatiu-e  rose  to  105°,  and  for  some  days  was  as  high 
as  104°,  with  delirium  and  distressing  vomiting.  Sometimes  the  ajjpear- 
ance  of  swelling  in  the  organ  secondarily  attacked  is  preceded  by  severe 
constitutional  symptoms.  There  may  be  high  fever  and  deluium  ;  or 
great  prostration  with  coldness  of  the  extremities  ;  or  Adolent  vomiting  and 
purging.  In  any  case,  great  alarm  is  excited  by  the  condition  of  the  suf- 
ferer; but  all  apprehensions  are  removed  by  the  appearance  of  the  local 
lesion.  These  comphcations  are  less  common  in  children  than  in  adults 
who  suffer  from  mumps,  but  it  is  w^ell  to  remember  that  it  is  possible  they 
may  occui\ 

There  is  another  and  occasional  after-consequence  of  mumps  which  it 
is  important  to  be  acquainted  with.  This  is  deafness,  coming  on  some 
time  after  the  parotiditis  has  subsided.  The  hearing  may  be  affected  in 
one  of  two  ways.  An  extension  of  the  inflammation  may  take  place  to  the 
Eustachian  tube  and  middle  ear.  These  cases  are  very  amenable  to  treat- 
ment and  usually  recover.  There  is,  however,  another  class  of  cases  of  a 
much  more  serious  character,  to  which  atteotion  has  been  directed  by  Mr. 
Dalby.  In  these  the  deafness  comes  on  quite  suddenly.  The  child  goes 
to  bed  with  his  hearing  perfect ;  in  the  morning  he  is  found  to  be  deaf. 
Little  can  be  done  for  this  form  of  deafness.  It  is  probably  dependent 
upon  some  altered  condition  of  the  auditory  nerve,  for  no  appreciable  lesion 
can  be  detected  in  the  auditory  apparatus.     Whether  the  loss  of  hearing 


MUMPS — DIAGNOSIS — TREATMENT.  67 

be  complete  or  merely  partial,  little  laoj)e  of  material  improvement  can 
be  entertained. 

In  some  rare  cases  an  attack  of  mumps  has  been  known  to  be  accom- 
panied by  facial  paralysis  from  extension  of  the  inflammation  to  the  Portio 
Dura. 

Diagnosis. — Mumps  can  only  be  confounded  with  inflammation  of  the 
parotid  gland  of  a  non-specific  character,  such  as  may  occur  in  the  course 
of  some  fevers— symptomatic  parotiditis,  as  it  has  been  called,  or  parotid 
bubo.  In  this  case  both  sides  of  the  face  may  be  attacked,  but  the  fact  of 
the  lesion  being  a  secondary,  and  not  a  primary  disease,  and  of  the  rapid 
suppuration  which  takes  place  when  the  inflammation  is  symptomatic, 
should  clear  up  any  uncertainty  which*  might  be  felt  as  to  the  nature  of 
the  case. 

Mumps  is  probably  infectious  from  the  very  beginning  of  the  disorder, 
and  remains  so  for  some  time  after  the  swelUng  has  subsided.  Dr.  Squire 
is  of  opinion  that  for  at  least  two  weeks  after  the  disease  has  cleared  away, 
the  child  should  not  be  allowed  to  return  to  his  healthy  companions. 

Treatment. — As  the  disease  cannot  be  arrested,  but  must  run  its  course, 
little  active  treatment  is  required.  It  is  best  to  put  the  child  to  bed,  and 
to  keep  him  there  as  long  as  the  temperature  is  elevated.  Hot  poultices 
should  be  applied  to  the  parotid  region  and  be  frequently  changed.  If  the 
pain  be  not  relieved  by  this  means,  an  ointment  composed  of  equal  parts 
of  extract  of  belladonna  and  glycerine  may  be  smeared  gently  upon  the 
skin  over  the  inflamed  glands,  and  the  poultice  be  applied  as  before.  The 
jaws  must  be  kept  at  rest,  and  no  solid  food  can  be  allowed.  Instead,  the 
child  should  have  strong  beef-tea  or  gravy  soup,  meat  jelly,  milk,  yolks  of 
eggs,  etc.  ;  but  if  there  be  high  fever,  with  foul  tongue  and  derangement 
of  the  digestive  organs,  as  is  most  usually  the  case,  the  stomach  must  not 
be  overloaded  even  with  liquid  food,  and  care  should  be  taken  to  supjDly 
nourishment  in  small  quantities  at  a  time.  If  the  fever  be  high  and  cause 
restlessness,  the  surface  of  the  body  can  be  sponged  with  tepid  water. 
The  bowels  must  be  attended  to  and  constipation  relieved  by  some  gentle 
aperient,  such  as  compound  liquorice  powder  or  the  liquid  extract  of 
rhamnus  frangula. 

In  cases  of  metastasis  to  the  mamma  or  testicle,  perfect  rest  must  be 
enforced  ;  and  the  local  treatment  recommended  for  the  face  should  be 
had  recourse  to.  The  alarming  symptoms  which  sometimes  precede  the 
appearance  of  the  secondary  lesion  usually  pass  away  in  the  course  of  a 
few  hours.  If  there  be  great  prostration,  stimulants  must  be  given,  and 
warmth  be  applied  to  the  extremities. 


CHAPTEE  YIII. 

CEREBEO-SPINAL  FEVER. 

(Epidemic  cerebro-spuaal  meniagitis. ) 

Ceeebro-spinal  fever  is  a  specific  inflammation  of  the  membranes  cover- 
ing the  brain  and  cord.  The  malady  is  no  mere  local  disorder,  but  a 
blood  disease,  of  which  the  inflammatory  affection  of  the  meninges  is  the 
anatomical  expression.  It  usually  prevails  in  epidemics,  and  outbreaks 
of  the  disease  have  been  noted  in  various  countries  v^idely  differing  in 
climatic  and  other  conditions. 

Causation.— The  epidemics  of  cerebro-spinal  fever  generally  occur  dur- 
ing the  vdnter  months  ;  but  isolated  cases  are  often  noticed  for  some  time 
before  the  disease  becomes  more  generally  difiiised.  Thus,  before  the  epi- 
demic which  prevailed  in  Ireland  in  1867,  sporadic  cases  had  been  observed 
in  the  country  for  some  years.  The  disease  appears  to  be  mildly  infectious. 
It  fastens  upon  old  and  young,  rich  and  poor,  but  males  appear  to  be  more 
liable  to  suffer  from  it  than  females.  In  1846  some  cases  occuiTed  in  the 
Dublin  and  Bray  Workhouses,  and  shortly  afterwards  in  the  Belfast  Work- 
house. In  these  cases  the  sole  victims  were  boys  under  the  age  of  twelve. 
The  girls  and  adults  escaped.  In  all  epidemics  children  are  largely  affected, 
for  unlike  typhus,  of  which  cerebro-spinal  fever  was  at  one  time  supposed 
to  be  merely  a  variety,  the  disease  readily  attacks  young  subjects,  and  is 
most  fatal  in  early  life.  Although  not  generated,  like  tj^hus,  by  insanitary 
conditions,  the  onset  of  the  fever  seems  to  be  favoured  by  them  ;  and  foul 
air,  bad  food  (especially  ergotized  gTain,  according  to  Dr.  Richardson), 
exposure  to  cold  and  damp,  and  physical  fatigue,  no  doubt  tend  to  encoui-age 
the  spread  of  this  fatal  malady. 

Morbid  Anatomy. — The  vessels  of  the  pia  mater,  both  of  the  brain  and 
cord,  are  congested,  and  lymph  is  exuded  into  the  subarachnoid  tissue. 
Sometimes  it  is  also  seen  in  the  ventricles.  It  usually  consists  of  opaque 
purulent  matter  of  a  greenish-yellow  color.  The  amount  varies.  It  may 
occur  only  in  patches,  or  may  be  more  general.  The  lymph  is  especially 
abundant  at,  or  is  confined  to,  the  base  of  the  brain — usually  the  posterior 
portion,  the  surface  of  the  medulla  oblongata,  and  the  upper  part  of  the 
spinal  cord.  Thei'e  is  often  congestion  of  the  substance  of  the  brain,  and 
there  may  be  serous  effusion  or  actual  extravasation  of  blood.  The  choroid 
plexus  is  much  congested,  and  the  cervical  part  of  the  cord  may  be  cov- 
ered with  a  thick  layer  of  bright-red  vessels.  In  the  worst  cases  of  the 
disease  the  blood  is  very  dark  in  colour  and  unusually  liquid. 

The  exudation  appears  to  be  thrown  out  with  great  rapidity,  for  it  may 
be  found  in  cases  where  death  occurred  within  a  few  hoiu-s  of  the  child 
being  attacked.  Ebert  and  others  have  found  micrococci  in  the  purulent 
effusion  of  the  meninges,  and  according  to  some  observers  the  disease  is 
essentially  due  to  micro-organisms. 


CEEEBEO-SPIlSrAL   FEVEE — MOEBID   AISTATOMY — SYMPTOMS.      69 

Of  the  other  organs':  the  spleen  is  generally  unaltered,  although, 
sometimes  it,  as  well  as  the  other  viscera,  may  be  congested.  There  may 
be  signs  of  pleurisy,  and  scattered  patches  of  hepatization  may  be  seen  in 
the  lungs.  It  is  said  that  the  agminated  and  solitary  glands  of  the  intestine 
have  been  found  in  some  cases  to  be  swollen. 

Symptoms. — The  disease  generally  begins  suddenly  during  sleep,  hav- 
ing been  preceded  by  few  or  no  premonitory  symptoms.  In  certain  cases 
— usually  the  milder  ones — the  child  may  complain,  if  old  enough  to  do  so, 
of  wandering  pains,  and  may  seem  poorly  for  a  day  or  two  before  the  out- 
break ;  but  there  is  seldom  anything  to  fix  the  attention  before  the  first 
violent  symptoms  of  the  disease  make  their  appearance.  In  rare  cases 
there  may  be  headache,  vomiting,  and  general  tenderness  for  some  days 
previous  to  the  actual  beginning  of  the  illness. 

As  a  rule,  the  first  noticeable  feature  is  a  rigour  or  a  fit  of  convulsions  ; 
and  the  younger  the  child,  the  more  likely  is  the  attack  to  begin  with  a 
convulsive  seizure.  Sometimes  severe  headache  and  vomiting  may  usher 
in  the  disease.  If  the  patient,  as  is  often  the  case,  seems  heavy  and 
stupid  after  the  fit,  he  stiU  shows  by  his  restlessness,  his  moans  and  cries, 
and  by  frequently  carrying  the  hand  to  the  head,  that  he  is  suffering  se- 
vere pain.  The  pupils  are  contracted  ;  the  pulse  is  quick,  seldom  lowered 
in  frequency  ;  the  temperature  (which  should  always  be  taken  in  the  rec- 
tum) is  101-2°  ;  and  the  breathing  is  hurried.  An  early  symptom  is  re- 
traction of  the  head  upon  the  shoulders.  It  has  been  suggested  that  this 
position  is  at  first  partly  voluntary,  to  relieve  the  pain  (which  we  know,  from 
the  case  of  the  adult,  to  be  of  a  very  severe  character)  shooting  down  the 
back  ;  but  it  soon  becomes  involuntary  from  spasmodic  contraction  of  the 
muscles  of  the  nucha.  It  may  occur  within  a  few  hours  of  the  onset  of 
the  illness,  and  is  rarely  delayed  beyond  twenty-four  hours.  The  tetanic 
spasm  of  the  muscles  of  the  neck  may  extend  to  the  whole  back,  the  jaws, 
or  even  the  limbs,  and  may  be  varied  by  clonic  convulsive  movements. 
In  a  short  time  the  cries  and  manifestations  of  pain  cease  as  the  senses  be- 
come duller  and  the  stupor  increases.  If  consciousness  is  lost  early  and 
does  not  return,  the  symptom  is  a  very  grave  one. 

About  the  second  or  beginning  of  the  third  day  a  herpetic  eruption 
appears  upon  the  face,  and  purpuric  spots  may  come  out  upon  the  body 
and  limbs.  This  eruption,  which  is  not  invariably  present,  has  given  to 
the  disease  one  of  its  names — "  spotted  fever. " 

When  the  disease  is  at  its  height,  the  child  lies  on  his  side  in  the  cot 
with  his  head  retracted,  his  limbs  flexed,  and  his  spine  often  rigidly 
curved.  He  is  completely  unconscious,  but  still  remains  uneasy  and  rest- 
less, often  moving  one  or  both  lower  limbs  monotonously.  The  pupils 
are  now  generally  dilated,  usually  sluggish,  and  perhaps  unequal.  The 
belly  is  flattened ;  the  bowels  are  constipated  ;  the  pulse  and  respirations 
are  quickened.  At  intervals  spasms  are  noticed  ;  the  head  is  drawn  more 
backward,  and  the  curve  of  the  spine  is  increased.  When  the  stupor  is 
complete  the  bladder  is  evacuated  involuntarily,  or  there  is  retention  of 
urine. 

In  fatal  cases  the  coma  continues,  the  breathing  is  accompanied  by 
rattling  within  the  chest,  and  the  child  sinks  and  dies.  If  the  case  is  to 
end  favourably,  the  stupor  grows  less  profound  and  the  restlessness  dimin- 
ishes. The  rigidity  is  late  in  relaxing,  and  usuall}^  the  mind  becomes 
clear  while  the  head  is  still  retracted  upon  the  shoulders. 

The  special  symptoms  above  referred  to  vary  considerably  in  severity 
in  particular  cases  : — 


70  DISEASE  IN   CHILDREN. 

The  fever  is  very  variable  and  lias  bo  regular  course.  The  internal 
heat,  as  tested  by  a  thermometer  introduced  into  the  rectum,  is  generally 
higher  than  the  surface  of  the  body ;  but  even  in  the  rectum  the  mercury 
may  only  mark  a  degree  over  the  normal  temperature.  At  other  times  it 
rises  to  104°  or  105°.  If  early  collapse  come  on,  the  temperature  may 
sink  to  below  the  normal  level. 

The  skin  eruption  is  a  valuable  sign.  In  some  epidemics  it  is  a  rare 
symptom  ;  in  others  almost  all  the  cases  exhibit  a  number  of  purpuric 
spots.  In  every  recorded  serious  outbreak  both  the  maculated  and  the 
non-maculated  forms  of  the  disease  have  been  observed,  although  one  may 
have  been  more  common  than  the  other.  The  rash  consists  of  dark 
purple  spots  or  blotches  due  to  effusion  of  dissolved  hsematin  into  the  true 
skin  and  areola  tissue  beneath  it.  They  generally  occupy  the  legs,  hands, 
face,  back,  and  neck.  They  are  sometimes  slightly  elevated,  and  vary  in 
size  from  a  pin's  head  to  a  walnut.  According  to  Dr.  J.  A.  Marston's  ob- 
servations in  the  epidemic  which  occurred  in  Ireland  in  the  year  1867, 
there  is  no  necessary  relation  between  the  occurrence,  the  number,  and  the 
extent  of  the  spots  upon  the  skin  and  the  amount  of  the  intra-cranial  and 
intra-spinal  mischief.  Dr.  Mapother,  referring  to  the  same  epidemic, 
states  that  the  spots  cannot  be  produced  artificially  by  pressure  on  the 
skin  as  in  true  purpura.  Besides  the  petechise,  there  may  be  herpes, 
urticaria,  and  patches  of  erythema  or  roseola.  The  skin  may  have  a 
dusky  tint  and  is  often  moist.     Cerebral  flush  is  not  a  marked  symptom. 

The  mental  condition  also  varies  in  different  cases.  When  the  disease 
is  violent  and  death  occurs  early,  the  child  may  be  unconscious  from  the 
first.  In  other  cases  stupor  comes  on  by  the  second  or  third  day.  In  the 
mildest  cases  the  mind  may  be  little  affected,  or  there  may  be  shght  de- 
lirium with  curious  hallucinations.  Thus,  Dr.  Lewis  Smith  refers  to  a 
case  in  which  the  child  answered  questions  with  perfect  clearness,  but 
constantly  mistook  his  mother  for  another  person.  Usually,  in  all  cases 
before  death  the  coma  is  profound. 

The  pains  referred  to  the  head  and  spine  are  always  a  distressing  and 
prominent  symptom.  They  are  often  so  severe  that  the  child,  until 
he  becomes  comatose,  is  constantly  moaning  and  screaming.  The  pain  is 
increased  by  movements  of  the  back,  and  especially  by  attempts  to  press 
the  head  forward.  The  general  tenderness  of  the  skin  adds  gTeatly  to  the 
child's  discomfort  ;  and  sometimes  a  touch  on  the  body,  as  in  moving  him 
to  alter  his  position,  causes  the  greatest  distress. 

In  some  cases  paralysis  is  noticed.  It  is,  however,  a  comparatively  rare 
symptom,  and  is  usually  partial,  being  limited  to  one  or  more  limbs.  It 
may  affect  the  cerebral  nerves,  especially  the  third,  the  sixth,  and  the 
facial.  The  lesion  of  the  nerve-trunks  is  due  to  purulent  infiltration  of 
the  neui'ilemma,  or  to  contraction  of  the  hyperplastic  connective  tissue  of 
the  nerve-sheath.  In  cases  of  recoveiy  the  paralysis  may  last  through  life, 
but  sometimes  it  passes  off  as  the  patient  improves. 

Convulsions,  general  or  partial,  are  comparatively  common  in  the  case 
of  children,  certainly  much  more  common  in  them  than  in  the  adult.  They 
are  especially  frequent  in  the  more  severe  forms  of  the  disease.  The  clonic 
spasms  sometimes  alternate  with  tonic  contractions  ;  and  may  be  general 
or  hmited  to  one-half  of  the  body.     Nystagmus  may  be  noticed. 

Vomiting  is  seldom  absent  at  the  beginning  of  an  attack.  It  is  often 
severe,  and  like  all  forms  of  nervous  vomiting  is  independent  of  taking 
food.  The  thirst  is  great.  Constipation  is  the  rule  ;  although  in  some  epi- 
derdics  the  disease  has  been  noticed  to  be  ushered  in  by  purging  as  well  as 


CEREBRO-SPINAL   FEVER — SYMPTOMS.  71 

vomiting.  The  tongue  may  be  clean  or  furred  ;  towards  tlie  end  of  tlie 
disease  it  becomes  dry.  Abdominal  pain,  if  present,  is  like  the  hypertes- 
thesia  of  nervous  origin.  The  belly  is  seldom  retracted,  and  never  to  the 
degree  observed  in  cases  of  tubercular  meningitis.  Occasionally  it  is  full 
or  even  tympanitic.     The  spleen  is  sometimes  enlarged. 

The  pupils  are  at  fii'st  contracted,  but  dilate  as  the  stupor  deepens. 
They  are  often  sluggish,  and  may  be  unequal  in  size.  A  squint  is  some- 
times noticed.  Blindness  may  occur  from  keratitis  owing  to  imperfect 
closure  of  the  eyelids,  or  from  neuro-retinitis  due  to  the  spread  of  the 
pui'ulent  inflammation  along  the  optic  nerve  ;  and  in  some  rare  cases  the 
eyeball  has  been  known  to  be  completely  destroyed  by  suppuration.  The 
hearing  may  be  also  affected.  A  temporary  deafness  with  noises  in  the 
head  may  occur  during  the  first  days  of  the  disease  and  be  afterwards  re- 
covered from.  If  it  occur  later,  it  is  probably  due  in  most  cases  to  purulent 
inflammation  within  the  labyrinth.  This  fonxi  of  deafness  is  usually  bi- 
lateral, complete,  and  permanent ;  and  if  the  patient  be  a  young  child,  may 
lead  to  deaf-mutism. 

The  pulse  is  seldom  otherwise  than  quickened  ;  but  it  rarely  attains  at 
fii'st  a  high  degree  of  frequency,  and  is  subject  to  rapid  alternations.  It  is 
not  often  intermittent,  but  is  usually  very  feeble.  The  breathing  is  also 
quickened,  and  is  often  irregular  and  interrupted  with  sighs.  The  normal 
relation  between  the  pulse  and  the  res^Dii-ation  is  presei^v^ed. 

The  urine  is  often  natural  in  quantity,  color,  and  reaction.  It  has  been 
known  to  contain  albumen  and  even  blood. 

There  are  many  differences  in  the  various  cases  of  cerebro-spinal  fever 
met  with  in  the  course  of  the  same  epidemic.  In  some  the  symptoms  from 
the  first  are  indicative  of  profound  blood-poisoning.  Consciousness  is  af- 
fected from  the  beginning ;  there  is  extreme  prostration,  a  feeble  flutter- 
ing pulse,  and  labored  breathing.  Then  spots  appear  early  and  are  ex- 
tensively distributed.  The  stupor  deepens  into  coma,  and  death  takes 
place  with  starthng  rapidity.  In  these  cases  the  more  special  symptoms 
arising  from  the  local  inflammation  are  overshadowed  by  those  dependent 
upon  the  general  condition,  and  the  patient  dies  from  blood-poisoning.  In 
another  class  of  cases  the  symptoms  of  cerebro-spinal  inflammation  pre- 
dominate, and  the  more  marked  phenomena  are  the  convulsions,  the  draw- 
ing backward  of  the  head,  the  hypersesthesia,  and  the  tetanic  contraction  of 
muscles.  In  this  form  if  the  disease  end  unfavourably,  death  is  owing  mainly 
to  the  local  lesion.  As  a  rule,  the  affection  is  most  severe  when  the  epidemic 
is  still  young.  As  the  cases  get  more  numerous  they  become  milder  ;  and 
at  the  end  of  the  epidemic  it  is  common  for  recoveries  to  take  place. 

In  some  instances  curious  intermissions  occur  in  the  disease.  These 
may  be  found  quite  at  the  onset,  evident  premonitory  symptoms  aj)pearing, 
passing  off,  and  retui'nuig,  perhaps  several  times,  before  the  actual  out- 
break occui's.  In  other  cases  during  the  course  of  the  disease  more  or  less 
complete  remission  of  the  sym2:)toms  lasting  for  several  hours,  or  a  day  may 
take  place.  According  to  Dr.  Frey,  this  is  veiy  common  at  the  end  of  the 
second  or  third  day.  Again,  dui'ing  convalescence  the  same  variations 
may  be  seen,  the  headache  and  retraction  of  head  being  at  times  distress- 
ing, at  other  times  scarcely  noticeable. 

According  to  Dr.  Oscar  Medin,  of  Stockholm,  infants  under  twelve 
months  old  are  especially  hable  to  the  disease.  At  this  early  age  the  ill- 
ness generally  ends  fatally  ;  but  sometimes  mild  cases  are  obser\-ed  lasting 
from  a  day  to  a  week.  This  physician,  who  at  the  Orphan  Asylum  of 
Stockholm  had  many  opportunities  of  observing  the  malady,  states  that  the 


72  DISEASE   IjST   CHILBEEjS'^. 

mild  cases  began  with  fever,  somnolence,  and  twitcliings  during  sleep.  In 
most  instances  there  were  other  symptoms,  esj)eciallj  duiing  sleep,  such  as 
restlessness,  great  heat  of  head,  changes  in  the  colour  of  the  face  and  in  the 
sensibility  of  the  body.  In  a  few  of  the  milder  cases  shght  convulsive 
sj)asms  were  noticed,  with  rigidity  of  the  hmbs  and  neck,  strabismus,  and  di- 
latation of  the  pupils  ;  but  in  such  cases  these  symj^toms  soon  disajDpeared. 
In  all  the  ejDidemics  which  came  under  Dr.  Medin's  observation  such  mild 
cases  were  the  exception,  and  a  large  proportion  of  the  infants  died.  In 
the  severer  forms  the  symjjtoms  did  not  differ  fi'om  those  observed  in  older 
children. 

Dr.  Medin,  like  other  observers  who  have  had  opi^ortunities  of  study- 
ing this  form  of  illness,  speaks  of  a  pneumonia  of  a  low  type,  occuriing 
without  nervous  symptoms,  as  being  frequently  present  in  epidemics  of 
cerebro-spinal  fever ;  and  holds  with  them  that  in  such  cases,  the  infective 
material  attacks  the  lungs  in  jDlace  of  the  cerebral  membranes.  StiU, 
meningitis  may  be  present  in  such  cases,  although  it  gives  rise  to  no  symp- 
toms ;  for  in  some  instances  where  cltuing  life  the  symptoms  were  exclu- 
sively pulmonary,  inflammation  of  the  cerebral  and  spinal  meninges  was 
discovered  on  post-mortem  examination  of  the  body.  Besides  pneumonia, 
peri-  and  endo-carditis,  pleurisy,  parotitis,  and  purulent  effusion  into  the 
joints  may  be  complications  of  the  disease. 

The  dtu'ation  of  the  attacks  is  veiy  variable.  Death  may  take  place  in 
five  or  six  hours  in  the  most  mahgnant  forms  of  the  distemper.  In  other 
cases  the  illness  may  be  jDrolonged  for  one,  two,  three,  or  foui'  weeks,  or 
even  longer.  Convalescence  is  always  slow,  and  is  often  intermittent.  A 
profound  debihty,  lasting  for  a  long  time  after  the  fever  is  at  an  end,  is  one 
of  the  characteristics  of  the  malady. 

Diagnosis. — Every  case  of  rigid  retraction  of  the  head  in  a  child  is  not 
one  of  cerebro-spinal  fever.  The  symptom  is  the  consequence  of  a  basic 
meningitis  spreading  to  the  cervical  portion  of  the  spinal  cord  ;  and  it  may 
therefore  be  present  in  any  case  where  the  membranes  of  the  brain  are  the 
seat  of  inflammation.  It  is  not  uncommon  in  the  course  of  a  tubercidar 
meningitis. 

Cerebro-spinal  fever  not  only  gives  rise  to  severe  local  symptoms,  but 
is  also  accompanied  by  more  general  phenomena  indicating  a  profound  con- 
stitutional affection.  Its  epidemic  form,  its  violent  and  abrupt  onset,  the 
extreme  debility  which  is  invariably  present,  and  the  petechial  rash,  remove 
the  disease  fi'om  the  Hst  of  purely  local  disorders,  and  amply  justify  its  be- 
ing ranked  amongst  the  specific  fevers.'  The  disease  was  at  one  time  held  to 
be  merely  a  form  of  ty|Dhus  fever  comphcated  with  meningitis  ;  but  the 
difference  between  the  two  diseases  are  neither  insignificant  nor  few.  Cere- 
bro-spinal fever  prevails  equally  amongst  the  rich  and  the  poor  ;  it  particu- 
larly affects  children,  and  is  very  fatal  to  them ;  it  runs  a  rapid  course, 
often  causing  death  in  a  few  hours ;  its  temperature  as  a  rule  is  little  ele- 
vated ;  the  rapidity  of  the  pulse  is  moderate,  and  when  the  fever  is  high, 
is  not  increased  in  proportion  to  the  degi'ee  of  pyrexia  (indeed,  according 
to  some  obseiwers,  it  does  not  become  rapid  until  the  temperatin-e  falls)  ; 
lastly,  retraction  of  the  head  is  one  of  the  most  common  symptoms. 

Typhus  loves  "fever  haimts,"  and  seldom  attacks  the  well-to-do;  it 
rarely  affects  children,  and  if  it  do,  runs  in  them  as  a  rule  an  especially 
favourable  course  ;  its  duration  is  longer,  and  even  in  the  adult  it  rarely  ap- 
pears in  the  overwhelming  and  mahgnant  form  so  often  seen  in  cases  of 
cerebro-spinal  fever ;  lastly,  meningitis  with  retraction  of  the  head  is  a  rare 
complication. 


CEREBRO-SPINAL   FEVER — DIAGNOSIS — PROGlSrOSIS.  73 

The  diagnosis  of  cerebro-spinal  fever  is  much  easier  in  the  midst  of  an 
epidemic  of  the  disease.  The  abrupt  and  violent  onset,  the  severe  pain  in 
the  head  and  spine,  the  vomiting,  the  retraction  of  the  head,  the  general  stu- 
por, and  the  petechial  and  other  eruptions — this  combination  of  profound 
constitutional  symptoms  with  nervous  excitement  followed  by  depression, 
is  sufficiently  characteristic,  especially  if  at  the  same  time,  as  often  hap- 
pens, the  temperature  is  only  moderately  raised  and  varies  irregularly.  In 
cases  of  simple  cerebro-spinal  meningitis  the  retraction  of  the  head  is  not 
so  extreme,  and  the  stiffness  and  pain  in  the  spine,  the  hypersesthesia,  and 
the  pains  in  the  joints  are  seldom  present.  As  a  rule,  too,  the  non-specific 
disease  is  preceded  by  prodromata  and  runs  a  less  rapid  course.  Still,  this 
is  not  always  the  case,  for  in  exceptional  instances  simple  meningitis  may 
prove  fatal  to  a  young  child  in  the  course  of  twenty-four  hours.  The  fever 
in  the  latter  is,  however,  always  high,  and  the  convulsions  are  in  most 
cases  repeated  and  general. 

It  would  be  difficult  to  confound  tubercular  meningitis  accompanied  by 
retraction  of  the  head  with  cerebro-spinal  fever.  The  hereditary  tubercu- 
lar tendency,  the  long  prodromal  period,  the  gradual  onset  of  the  illness, 
the  more  protracted  and  characteristic  course,  and  the  slow  intermittent 
pulse,  would  serve  to  distinguish  the  tubercular  disease. 

In  infants  under  twelve  months  old  the  disease  is  very  difficult  to  de- 
tect. It  may,  however,  be  distinguished  by  close  attention  to  the  course 
and  symptoms  of  the  illness  ;  especially  if  the  case  occur  in  the  midst  of  an 
outbreak  of  the  malady. 

Prognosis. — In  all  cases  of  cerebro-spinal  fever  the  prognosis  is  very 
serious.  The  disease  is  especially  fatal  to  children,  and  the  younger  the 
patient  the  less  hope  can  we  entertain  of  a  favourable  termination  to  his 
illness. 

In  babies  an  arched  and  tense  fontaneUe,  which  shows  the  presence  of 
profuse  exudation  and  oedema,  is  a  very  grave  symptom.  In  aU  cases  re- 
peated convulsions  and  signs  of  severe  nervous  excitation,  such  as  violent 
and  incessant  vomiting,  intense  cephalalgia  and  pain  in  the  back,  strong 
tetanic  spasms  ;  also  early  appearance  of  depression,  continuous  coma  or 
return  of  the  stupor  after  a  period  of  apparent  improvement,  and  irregular 
breathing,  are  all  signs  calculated  to  excite  the  gravest  apprehensions. 

Treatment. — The  disease  unfortunately  is  little  amenable  to  treatment. 
In  all  cases  ice-bags  should  be  applied  to  the  head  and  spine  as  long  as  the 
period  of  excitement  continues.  When  symptoms  of  depression  are  no- 
ticed, the  ice  should  be  removed,  or  supplemented  by  the  application  of 
hot  bottles  to  the  feet,  and  the  administration  of  stimulants  by  the  mouth. 
Sometimes  hot  applications  relieve  the  severe  headache  better  than  cold. 
The  ether  spray  has  been  used  to  the  occiput  and  back  of  the  neck,  and  is 
said  to  be  of  service.  Large  doses  of  clJoral  sufficient  to  produce  signs 
of  narcotism  have  been  recommended.  All  writers,  however,  speak  highly 
of  the  subcutaneous  injection  of  morphia.  For  a  child  of  three  years  of 
age  one-twentieth  of  a  grain  may  be  used,  and  repeated  every  one  or  two 
hours  until  some  sensible  effect  is  produced  ;  or  four  or  five  grains  of 
chloral  may  be  given  by  the  mouth. 

During  protracted  convalescence  the  iodide  of  potassium  must  be  given 
to  further  absorption^  of  the  exudations  ;  and  iron  and  tonics,  with  removal 
to  a  dry  bracing  aii",  are  of  value  to  hasten  the  child's  recovery. 


CHAPTER  IX. 

ENTERIC  FEVER. 

Enteric  or  typhoid  fever  is  common  in  children.  A  large  proportion 
of  the  cases  formerly  described  as  "Infantile  Remittent  Fever"  were  no 
doubt  cases  of  this  disease.  Fortunately  in  young  subjects  typhoid  fever 
usually  runs  a  mild  course.  It  would  be,  no  doubt,  too  much  to  say  that, 
properly  treated  and  nui'sed,  no  child  should  die  of  tj^^hoid  ;  but  certainly 
when  placed  from  the  beginning  under  favourable  conditions  for  recovery, 
death  in  the  child  from  such  a  cause  is  very  rare. 

Infants  and  children  during  the  first  four  or  five  years  of  life  seem  less 
susceptible  to  the  typhoid  poison  than  at  a  later  age.  Perhaps,  however, 
it  is  difficult  to  recognize  the  disease  in  such  young  subjects  ;  and  it  is  not 
impossible  that  many  cases  of  febrile  diarrhoea  in  the  young  child  may  be 
cases  of  typhoid  fever  which  have  escajDed  recognition.  Boj^s  are  more 
commonly  affected  than  girls  ;  and  the  fever  seems  to  attack  b}^  preference 
previously  healthy  children.  At  any  rate  the  patients  who  are  brought 
suffering  from  the  disease  to  the  Children's  Hospitals  are  generally  well- 
nourished,  strong-looking  little  persons,  with  exceptionally  good  histories. 

Causation. — It  is  now  well  known  that  enteric  fever  arises  as  the  con- 
sequence of  absorption  into  the  system  of  a  specific  poison  which  is  gen- 
erated by  the  decomposing  discharges  of  tj^hoid  patients.  It  is  therefore 
largely  distributed  by  the  emanations  from  cesspools  and  faulty  drains. 
Warm  weather,  which  encourages  putrefaction,  increases  the  prevalence  of 
the  fever.  Dr.  Murchison  has  shown,  from  the  records  of  the  London 
Fever  Hospital,  that  cases  of  enteric  fever  become  more  numerous  after  the 
warmth  of  summer,  and  diminish  in  number  after  the  cold  of  the  winter 
months.  Thus,  in  August,  September,  October,  and  November,  the  fever 
prevails  largely ;  while  in  February,  March,  April,  and  May,  it  is  much 
less  frequently  seen.  Whether  the  poison  can  be  generated  de  novo  is  a 
question  which  has  been  often  debated  and  on  which  opposite  opinions 
are  held.  It  seems  certain  that  the  decomposition  of  ordinary  fecal 
matter  under  ordinary  conditions  of  atmosphere  cannot  produce  it ;  but  it 
is  probable  that  the  specific  poison  may  be  generated  from  non-specific 
ordure  under  extraordinary  conditions.  At  least,  it  is  difficult  under 
any  other  hypothesis  to  explain  outbreaks  of  the  fever  in  country  villages 
where  the  strictest  search  fails  to  discover  any  means  by  which  the  disease 
can  have  been  imported  from  without,  and  in  which  the  same  insanitary 
state  has  existed  unchanged  for  years.  There  is  no  doubt  that  the  dis- 
charges from  the  patient  are  highly  contagious.  The  disease  cannot,  how- 
ever, be  communicated  by  the  breath  or  by  emanations  from  the  skin.  It 
is  held  by  some  that  the  discharges  themselves'  are  at  first  comparatively 
innocuous,  and  only  become  hiu'tful  after  putrefaction  has  begun. 

The  poison  enters  the  system  by  the  mucous  membrane  of  the  lungs 
or  of  the  alimentary  canal.     In  most  cases,  no  doubt,  contaminated  water 


ENTERIC   FEVER — CAUSATION — MORBID   ANATOMY.  75 

is  the  means  by  whicli  it  is  conveyed.  Several  epidemics  of  typhoid  fever 
in  London,  of  late  years,  have  been  traced  to  milk  to  which  v^ater  contain- 
ing typhoid  matter  had  been  added.  It  is  also  probable  that  untrapped  or 
faulty  drains,  allowing  the  effluvia  of  cesspools  charged  with  the  specific 
poison  to  penetrate  into  a  house,  may  be  another  means  of  imparting  the 
disease. 

One  attack  of  typhoid  fever  does  not  necessarily  protect  against  anoth- 
er ;  and  relapses  are  very  common. 

Morbid  Anatomy. — The  characteristic  lesion  in  typhoid  fever  consists  in 
a  swelling  of  the  solitary  glands  of  the  small  intestine,  of  the  agminated 
glands  constituting  Peyer's  patches,  and  of  the  mesenteric  glands  in  con- 
nection with  them.  The  swelling  is  a  pure  proliferation  of  the  cellular 
elements,  which  are  seen  by  the  microscope  to  be  much  increased  in  num- 
ber. Some  corpuscles  become  enlarged  and  develop  smaller  cells  within 
their  walls.  The  hypertrophic  change  in  the  glands  begins  early,  prob- 
ably at  the  beginning  of  the  disease,  and  proceeds  rapidly.  It  involves  a 
certain  number  of  Peyer's  patches.  These  ai'e  fully  developed  by  the 
ninth  or  tenth  day,  and  form  thick  oval  plates  with  alDrupt  edges  and  an 
uneven,  mammilated  surface.  Their  consistence  is  softer  than  natural,  and 
more  friable.  The  solitary  glands  may  be  unaffected  ;  but  they  also  often 
swell  and  form  small  projections  from  the  surface  of  the  mucous  mem- 
brane. After  reaching  their  full  size  the  glands,  in  mild  cases,  begin 
slowly  to  shrink.  The  newly  proliferated  cells  undergo  a  fatty  degeneration 
and  are  absorbed.  The  mesenteric  glands  also  diminish  in  size  by  the 
same  process  of  fatty  degeneration,  and  gradually  resume  their  former 
dimensions. 

In  more  severe  cases  the  diseased  glands,  instead  of  undergoing 
healthy  resolution,  take  on  a  further  morbid  action.  Small  points  of  ul- 
ceration appear  on  the  surface  of  the  patch.  These  enlarge  and  unite  so 
as  to  form  an  ulcer  which  may  cover  the  whole  of  the  diseased  surface. 
Sometimes,  instead  of  ulcerating  at  separate  points,  the  mucous  membrane 
covering  the  affected  patch  sloughs  over  a  larger  or  smaller  area  and  sep- 
arates from  the  tissue  beneath.  If  the  whole  of  the  patch  have  been  thus 
luicovered,  the  resulting  ulcer  is  oval,  and  has  its  longer  axis  in  the  direc- 
tion of  the  canal.  Smaller  ulcers  maybe  circular  or  sinuous.  The  solitary 
glands  may  also  go  through  the  same  j)rocess,  and  leave  smaU,  round  ul- 
cers scattei'ed  over  the  surface  of  the  mucous  membrane.  The  edges  of 
the  ulcers  are  thick  and  sharply  cut,  or  even  undermined  ;  and  the  floor 
is  formed  by  the  submucous  tissue,  the  muscular  coat,  or,  in  bad  cases, 
merely  by  the  peritoneal  covering  of  the  bowel. 

After  a  time,  a  process  of  repair  is  set  up  and  the  ulcers  begin  to  heal. 
This  favourable  change  seldom  occurs  before  the  end  of  the  third  week,  and 
the  process  of  cicatrization  occupies  a  variable  time.  Under  favourable  con- 
ditions it  may  be  completed  in  two  or  three  weeks,  but  it  is  often  spread 
over  a  longer  period.  The  healing  of  the  ulcer  is  not  followed  by  any  con- 
traction of  the  iDOwel. 

The  morbid  process  above  described  attacks  especially  the  glands  in 
the  neighbourhood  of  the  ileo-caecal  valve,  and  extends  upwards  for  a  varia- 
ble distance.  In  some  cases  the  sohtaiy  glands  in  the  ctecum  and  part 
of  the  ascending  colon  may  be  also  affected.  The  deeper  ulcers  are  usu- 
ally in  the  lower  part  of  the  ihum  near  the  valve  ;  and  when  perforation 
occurs,  it  is  by  rupture  of  one  of  these,  whose  floor  is  formed  only  by  the 
peritoneal  coat  of  the  intestine.  That  this  accident  does  not  occur  oftener 
is  due  to  a  local  peritonitis  having  been  set  up,  gluing  the  affected  part  of 


76  DISEASE   IN   CHILDREIS'. 

the  bowel  to  a  neiglibouring  organ.  Children  who  die  from  this  disease 
die  almost  invaiiably  from  perforation  of  the  bowel ;  but  an  unfavorable 
ending  to  enteric  fever  is  comjDaratively  a  rare  accident  in  young  sub- 
jects, in  whom  the  unhealthy  action  in  the  glands  often  stops  short  of 
ulceration. 

Besides  the  special  changes  in  the  glands,  the  whole  mucous  mem- 
brane of  the  bowel  is  swollen  and  relaxed.  The  enlarged  mesenteric 
glands  seldom  suppurate  in  the  cliild.  They  usually  rapidly  undergo  res- 
olution as  soon  as  the  process  of  repaii-  has  begun  in  the  intestine.  The 
spleen  is  enlarged  and  congested.  It  is  dark  red  in  color  and  is  softer 
than  natural.  The  kidneys  are  sometimes  congested.  In  all  cases  of  ty- 
phoid fever  the  lungs  are  the  seat  of  catarrh,  so  that  the  mucous  mem- 
brane of  the  aii'-tubes  is  red  and  congested,  and  the  bronchial  glands  are 
enlarged  and  vascular. 

Symptoms. — After  exposure  to  the  contagious  poison  there  is  a  period 
of  incubation  varying  fi-om  ten  days  to  a  fortnight,  at  the  end  of  which 
the  symptoms  of  the  fever  begin  to  manifest  themselves.  These  are  at 
first  very  slightly  marked  ;  so  much  so,  that  it  is  sometimes  difficult  to  fix 
the  exact  time  at  which  the  illness  began.  In  most  cases,  however,  careful 
questioning  of  the  jDarents  will  enable  us  to  determine  the  fu*st  day  of  the 
disease.  One  of  the  earhest  symptoms  is  frontal  headache.  It  is  com- 
mon to  be  told  that  a  child  returned  from  school  saying  he  had  a  headache, 
that  he  looked  pale,  was  languid  and  could  eat  no  dinner.  There  is  fever 
at  this  time,  but  the  child,  not  being  supposed  to  be  really  ill,  is  not  treated 
as  an  invalid.  In  other  cases  headache  is  not  complained  of  at  fii'st.  The 
child  is  merely  pale  and  hstless,  with  some  fever,  and  cannot  be  persuaded 
to  eat.  For  the  first  few  days  little  else  can  be  discovered.  The  tongue 
is  coated  with  a  thiu,  white  fur,  through  which  red  papillse  project.  There 
is  often  slight  redness  of  the  throat.  The  bowels  are  either  confined,  or 
one  or  two  loose,  rather  offensive,  stools  are  passed  in  the  twenty-foiu* 
hours.  The  child  is  drowsy,  but  sleeps  restlessly,  although  without  de- 
lirium. He  generally  complains  of  his  head,  and  often  of  achmg  pains 
about  the  body  and  limbs.  Sometimes  there  is  vomiting  after  food,  and 
there  may  be  trifling  epistaxis.  Cough  is  a  more  or  less  constant  symp- 
tom, but  varies  greatly  in  amount.  Usually  it  is  insignificant  at  the  first. 
During  this  time,  unless  medical  assistance  be  summoned,  the  patient  is 
seldom  confined  to  his  bed,  but  is  dressed  in  the  morning  as  usual.  In- 
deed, in  mild  cases,  children  will  often  walk  considerable  distances  to  the 
out-patients'  room  of  a  hospital,  for  the  muscular  weakness  is  much  less 
marked  than  might  be  anticipated. 

So  far,  then,  the  symptoms  are  vague  ;  and  if  it  were  not  for  the  de- 
cided character  of  the  "^pyrexia,  there  would  be  nothing  to  help  us  to  coine 
to  any  conclusion  as  to  the  nature  of  the  illness.  It  is  only  at  the  end  of 
the  first  week  that  more  characteristic  symptoms  are  obseiwed.  About 
the  sixth  or  seventh  day  the  spleen  begins  to  enlarge.  The  organ  can  be 
felt  to  j)roject  inward  towards  the  middle  line  from  under  the  cover  of  the 
ribs.  Its  texture  is  soft,  so  soft,  indeed,  in  many  cases,  that  the  enlarge- 
ment can  be  only  detected  by  a  practised  finger  ;  and  it  appears  to  be 
tender,  for  pressui-e  over  its  substance  usually  produces  some  manifes- 
tation of  discomfort.  Tenderness  can  generally  be  noticed  at  this  time 
over  the  whole  belly,  and  is  not  confined  to  the  region  of  the  spleen.  The 
belly  is  now  a  little  swollen  ;  borborygmi  are  frequent ;  and  gau-gliug  may 
be  often  felt  on  pressure  in  the  right  iliac  fossa.  This,  however,  is  a 
symptom  as  often  absent  as  present.     The  bowels  are  relaxed  in  the  ma- 


EjSTTEEIC   FEVEE — SYMPTOMS.  77 

jority  of  cases,  although,  as  a  rule,  only  moderately  so,  and  the  stools 
exliibit  the  yellow  ochre  "pea-soup  "  appearance  which  has  been  so  often 
remarked  upon.  Still,  constipation  is  a  moi'e  common  phenomenon  in 
the  child  than  it  is  in  the  adult,  occurring  in  at  least  one-third  of  the 
cases. 

The  headache  now  usually  subsides,  and  the  patient  begins  to  have 
slight  delirium  at  night.  He  asks  constantly  for  drink,  but  seldom  shows 
any  disposition  to  take  food.  His  expression  at  this  time  is  dull  and 
heavy,  and  he  lies  quietly  on  his  back,  often  with  a  dull  flush  on  his 
cheeks,  taking  little  notice  of  what  passes  around  him.  By  the  end  of 
the  first  week  the  fever  has  reached  its  maximum.  The  skin,  however, 
although  generally  dry  is  not  always  so,  and  there  is  occasionally  a  ten- 
dency to  perspiration.  The  breathing  is  quickened,  and  the  frequency 
of  the  pulse  is  increased.  There  is  no  constant  relation  between  the  pulse 
and  the  heat  of  the  body.  The  pulse  may  be  only  moderately  quick 
with  a  high  temperatui-e,  and  its  rapidity  undergoes  frequent  variations. 

(Thus,  Edith  H ■,  aged  thirteen,  on  the  eighth  day  at  9  p.m.  :  pulse,  86  ; 

respiration,  36  ;  temperature,  103.6°.  At  9  a.m.  on  the  following  morning  : 
pulse,  100  ;  respiration,  36  ;  temperature,  100.8°.)  By  the  end  of  the  first 
week  the  cough  becomes  more  troublesome,  and  may  assume  such  prom- 
inence that  a  lung  affection  is  suspected  ;  but  only  dry  rhonchus,  with  per- 
haps an  occasional  coarse  bubble,  is  heai'd  about  the  chest. 

After  the  eighth  day  the  typhoid  eruption  should  appear.  In  children 
this  symptom  is  sometimes  absent ;  but  careful  insjoection  of  the  chest, 
abdomen,  and  back  will  generally  discover  a  few — it  may  be  only  one  or 
two — of  the  characteristic  spots.  Sometimes  they  can  be  detected  upon 
the  limbs.  The  rash  appears  in  the  form  of  small,  slightly  elevated,  len- 
ticular spots  of  a  delicate  rose  tint,  varying  in  size  from  half  a  line  to  a  line 
and  a  half,  and  disappearing  completely  under  pressure  of  the  finger. 
Their  number  varies,  but  they  may  be  very  numerous.  These  spots  come 
out  in  successive  crops,  each  one  lasting  two  or  three  days.  If  scanty,  they 
have  to  be  searched  for  with  great  care,  especially  when  the  back  is  examined, 
for  here,  on  account  of  the  general  congestion  of  the  surface,  they  may  not 
be  readily  seen. 

In  this  the  second  week  of  the  illness  as  each  day  passes  the  child  seems 
to  become  duller  and  more  indifferent.  He  is  drowsy  and  sleeps  much 
during  the  day,  but  at  night  may  be  more  restless,  and  sometimes  he  tries 
to  leave  his  bed.  His  weakness  has  now  become  more  marked.  The  pulse 
is  quick  and  feeble ;  and  towards  the  end  of  the  week  muscular  tremors 
and  twitchings  may  be  noticed.  The  beUy  is  much  swollen  and  assumes 
the  characteristic  barrel  shape.  The  looseness  of  the  bowel  continues,  or 
is  replaced  by  constipation,  and  sometimes — although  this  is  rare  in  the 
child — the  motions  contain  blood.  At  this  time  the  heart-sounds  become 
feeble  and  soft  to  the  ear,  and  there  is  often  a  prolongation  of  the  first 
sound  at  the  apex,  or  even  a  soft  systolic  murmur.  On  the  other  hand,  in 
old  standing  cases  of  cardiac  disease  a  murmur  previously  heard  may  be 
lost  as  the  heart's  action  becomes  enfeebled,  only  to  reappear  when  the 
strength  is  restored. 

In  the  third  week  of  the  illness  the  fever  usually  begins  to  diminish. 
In  the  mild  cases  the  temperature  becomes  natural  as  early  as  the  fourteenth 
day.  If  it  persist,  its  mean  is  lower  than  before,  and  the  morning  tem- 
peratui'e  may  be  almost  normal.  The  feebleness  of  the  patient  is  now 
sufficiently  pronounced,  but  as  the  daj's  pass  by  his  symptoms  become 
more  favourable.     He  grows  less  heavy  and  lethargic ;  the  swelling  of  his 


78  DISEASE  IN   CHILDEEX. 

belly  dimirdslies ;  the  spleen  retires  under  tte  ribs ;  diarrlioea,  if  it  had 
previously  existed,  ceases,  and  the  motions  become  more  natural ;  and  as 
the  tongue  cleans,  the  child  begins  to  show  some  dissatisfaction  at  being 
still  restricted  to  hquid  food.  As  the  fever  subsides,  the  pulse  often  be- 
comes intermittent,  and  is  very  soft  and  compressible.  T\Tien  the  fever 
is  at  an  end  the  child  is  left  very  weak  in  the  mildest  cases,  and  he  only 
slowly  regains  his  strength.  In  bad  cases  the  prostration  is  very  great,  and 
the  child  has  to  be  nursed  through  a  protracted  period  of  convalescence. 
Sometimes  cedema,  more  or  less  general,  is  seen  as  a  consequence  of  the 
impoverished  state  of  the  blood. 

The  above  is  a  sketch  of  the  ordinary  course  of  enteric  fever  in  the 
child.  There  are,  however,  many  variations  in  the  symptoms,  and  it  is 
desirable  therefore  to  refer  again  to  some  of  the  princij)al  phenomena. 

TJie  Digestive  Organs. — The  tongue  in  mild  cases  remains  moist  through- 
out the  whole  course  of  the  illness.  It  has  a  dehcate  coating  of  gTayish 
fur,  through  which  the  papillae  ai'e  seen  to  project.  The  tip  and  edges  are 
only  moderately  red.  Thirst  is  often  a  marked  symptom,  and  liquid  food 
is  taken  readily  to  satisf}'  this  craving  for  fluid.  AjDpetite  is  generally  lost, 
but  not  in  every  case.  A  little  ^oy  in  the  East  London  Cbildi-en's  Hospital 
complained  to  me  on  the  sixth  day  of  the  disease  that  he  was  himgry, 
although  his  temperature  was  then  105°,  and  his  tongue  was  thickly  fui-red, 
with  sordes  on  the  hps.  His  mind  was  quite  clear.  If  the  symptoms  are 
severe  the  tongue  generally  becomes  dry  in  the  course  of  the  second  week. 
It  may  be  fissured  across  the  dorsum,  and  the  hjDS  may  be  cracked  and 
blackened.  Sore  throat  is  a  very  common  symptom  during  the  fu'st  few 
days,  and  there  is  some  httle  redness  of  the  fauces.  Vomiting  is  fi-equent 
at  the  beginning  ;  occasionally  it  reciu'S  later  and  may  then  give  trouble. 

The  sweUing  of  the  abdomen  is  due  to  accumulation  of  flatus  through 
decomposition  of  food  and  inability  of  the  bowels  to  expel  their  gaseous 
contents.  This  loss  of  contractihty  is  the  consequence  of  lack  of  nen-e- 
power  or  of  local  injury  from  ulceration.  Consequently,  if  in  the  third 
week  of  illness  there  is  deep  ulceration  of  the  intestine  and  great  bodily 
prostration,  the  distention  of  the  belly  may  be  extreme.  The  amount  of 
abdominal  tenderness  varies.  In  the  mildest  cases  it  may  be  absent,  '\^'hen 
present  it  may  be  local,  limited  to  the  splenic  region  and  the  right  ihac 
fossa,  or  may  be  general  over  the  abdomen.  It  is  sometimes  a  well-marked 
symptom,  the  slightest  touch  being  productive  of  great  pain,  and  this  in 
cases  where  there  is  no  reason  to  suspect  the  presence  of  peritonitis.  The 
bowels  may  be  confined  throughout,  or  loose  throughout,  or  constipation 
may  alternate  with  a  mild  diarrhoea.  It  must  be  remembered  that  loose- 
ness of  the  bowels  is  due  not  to  the  ulceration  but  to  coexisting  catarrh.  If 
catarrh  be  insignificant  or  absent,  the  bowels  are  not  relaxed.  As  a  rule,  in 
children  the  looseness  is  not  extreme  and  is  easily  controlled.  The  relaxed 
motions  always  assume  at  one  time  or  another  the  "  pea-soup  "  character  ; 
they  have  an  alkahne  reaction  and  a  faint  oflensive  smell.  Haemorrhage 
from  the  bowels  to  any  amount  is  rai'e,  but  small  black  clots  of  blood  may 
be  sometimes  found  in  the  grumous  matter  at  the  bottom  of  the  stools. 

The  urine  is  at  first  scanty,  v\ith  a  high  density.  It  contains  an  excess 
of  tu'ea  and  uiic  acid,  but  is  poor  in  chlorides.  Later  it  becomes  more 
copious,  the  specific  gravity  falls,  and  it  may  contain  a  trace  of  albumen. 
During  the  height  of  the  fever  there  may  be  retention  of  urine,  with  dis- 
tention of  the  bladder  and  tenderness  over  the  pubes.  Sometimes  the 
catheter  has  to  be  employed.  There  is  no  gravity  about  this  symptom, 
and  it  need  cause  no  anxiety  if  care  be  taken  to  empty  the  bladder  by 


ENTERIC  FEVER — SYMPTOMS.  79 

degTees.  The  distention  is  due  to  loss  of  contractile  power  of  the  muscu- 
lar coat.  If,  then,  a  greatly  distended  bladder  be  suddenly  and  com- 
pletely emptied  of  its  contents,  the  organ  contracts  imperfectly,  and  a  cer- 
tain amount  of  air  enters  and  causes  great  irritation.  An  obstinate  cystitis 
may  be  produced  in  this  way. 

The^ju/.se  is  quick  as  a  rule,  but  sometimes  for  a  time  sinks  in  rapidity 
although  the  fever  continues  high.  The  frequency  of  the  -pvlse  is  not,  as 
has  already  been  stated,  any  trustworthy  guide  to  the  degree  of  fever  ;  nor, 
as  taken  at  a  single  examination,  is  it  necessarily  any  test  of  the  severity 
of  the  illness. 

The  respirations  are  hurried,  and  there  may  be  slight  distiu'bance  of 
the  normal  pulse-respiration  ratio  without  any  pulmonary  complication 

being  present.     (Thus  John  H ,  aged  four  years,  sixth  day,  4  p.m.  : 

temperature,  103^;  pulse,  120  ;  res^Diration,  46).  If  a  pulmonary  compUca- 
tion  actually  arise,  the  breathing  increases  in  rapidity  and  there  is  lividity 
of  the  face. 

The  skin  may  be  moist  at  times  duiing  the  course  of  the  disease,  and 
towards  the  end  of  the  third  week,  especially  if  the  fever  has  subsided, 
there  may  be  copious  sweating.  Sudamina  then  appear  on  the  chest. 
The  abundance  of  the  rash  varies  gi-eatly  in  different  cases.  It  may  be 
veiy  copious  or  completely  absent ;  but  these  extremes  bear  no  relation  to 
severity  or  mildness  of  attack.  It  is  well  to  be  aware  that  fresh  crojDS  of 
rose-spots  may  continue  to  ajDpear  for  a  week  after  the  temperature  has 
faUen  to  the  normal  level.  I  have  noticed  this,  on  several  occasions.  The 
facies  is  important.  The  child  seldom  looks  very  ill  in  the  early  stage  ; 
and  even  later,  unless  the  abdominal  mischief  be  severe,  it  is  exceptional 
for  his  face  to  wear  the  anxious  haggard  look  which  is  so  common  in  many 
other  serious  diseases,  and  forms  such  a  striking  feature  in  acute  tubercu- 
losis. In  ordinary  cases  the  expression  is  more  stupid  and  Hstless  than 
anxious. 

The  special  senses  may  be  affected.  Deafness  is  common.  Epistaxis 
is  a  frequent  symptom,  and  may  be  repeated  again  and  again.  The  con- 
junctivEe  look  red,  and  the  pupils  are  large.  The  headache  in  children  is 
seldom  very  severe.  It  ceases  about  the  end  of  the  first  week,  when  the 
delirium  begins.  Sometimes  cervical  neuralgia  is  noticed  after  the  second 
week,  and  every  movement  of  the  neck  may  be  accompanied  by  pain.  De- 
lirium is  the  rule,  beginning  towards  the  end  of  the  first  week.  Some- 
times from  this  cause  older  children  try  to  get  out  of  bed  and  are  noisy. 
Convulsions  may  precede  death  in  fatal  cases  ;  but  typhoid  fever,  unlike 
many  other  febrile  complaints  in  childhood,  is  very  rarely  ushered  in  by  a 
convulsive  attack.  StiU,  a  form  of  disease  is  usually  described  in  which 
the  early  symptoms  are  those  of  high  nervous  excitement.  The  child  is 
convulsed  and  has  marked  delirium.  I  have  never  met  with  a  case  of  this 
form  of  typhoid  fever  in  a  young  subject. 

The  'pyrexia,  like  most  forms  of  febrile  movement  in  the  child,  is  re- 
mittent, but  the  degree  of  remission  varies  at  different  periods  of  the  dis- 
ease. In  the  second  week  there  is,  as  a  rule,  less  variance  between  the 
maximum  and  minimum  temperatures  than  at  an  earlier  or  a  later  stage  of 
the  comj)laint.  To  test  the  bodily  heat  with  any  exactness,  the  tempera- 
tui'e  should  be  taken  every  three  or  four  hours,  both  day  and  night.  Very 
false  conclusions  may  be  drawn  from  a  merely  diui'nal  use  of  the  ther- 
mometer, for  the  mercury  is  not  necessarily  at  its  lowest  point  at  8  or  9 
A.M.,  nor  at  its  highest  at  6  or  7  o'clock  in  the  evening.  Again  the  mini- 
mum temperature  may  be  non-febrile,  or  even  subnormal.     (Thus,  in  the 


80  DISEASE   I]S-   CHILDRE]Sr. 

case   of  Lilly  F ,  aged   eleven   years,  a  patient  in  the  East  London 

Children's  Hospital,  the  temperature  during  the  morning  houi's  from  8 
o'clock  to  noon  was  subnormal  after  the  ninth  day.  It  was  often  as  low 
as  97°,  and  yet  this  was  an  undoubted  case  of  typhoid  fever.  In  the  even- 
ing the  heat  was  102"  or  103".)  It  is  difficult  to  lay  down  a  rule  in  a 
matter  which  is  subject  to  such  endless  variety  ;  but  jDerhapsthe  minimum 
temperature  is  reached  more  often  between  the  houi's  of  10  a.m.  and  noon 
than  at  any  other  time,  and  the  maximum  shortly  before  midnight  or  in 
the  early  morning  hours.  In  the  third  week  of  the  disease  the  remissions 
generally  become  very  marked,  and  the  minimum  registered  is  often  Uttle 
higher  than  a  normal  temperatm-e.  This  is  especially  noticeable  towards 
the  end  of  the  week. 

Dm'ing  the  first  few  days  of  the  fever  it  is  rare  for  the  child  to  be  under 
skilled  obsers'ation,  and  a  record  of  the  temperature  at  this  time  is  not 
easy  to  obtain.  Occasionally,  however,  a  hospital  patient,  admitted  for 
some  chi'onic  complaint,  sickens  of  the  disease.  Such  a  case  occuiTed 
lately  in  a  httle  gfrl,  aged  nine  years,  who  was  being  treated  for  hip-joint 
disease  in  the  East  London  Children's  Hospital  by  my  colleague  ^h\ 
Parker,  and  was  transferred  to  my  care  on  the  outbreak  of  the  fever.  The 
child,  whose  temperature  had  been  normal,  complained  of  headache  at  2  p.m. 
Her  temperature  was  then  formd  to  be  102.6°.  At  10  p.m.  it  had  fallen  to 
100°.  On  the  second  day,  at  6  a.m.,  it  was  99°  ;  but  rose  gradually,  being 
taken  every  foui'  houi's,  till  6  p.m.  when  the  thermometer  marked  103.2°. 
It  then  fell  suddenlv  to  99°  at  10  p.m.  On  the  thfrd  day  at  10  a.m.  it  was 
102.1°  ;  at  2  p.m.,  102.4°  ;  at  6  p.m.,  101.8°  ;  at  10  p.m.,  102.6°.  After  this 
it  varied  between  101°  and  103.8°  in  the  twenty-foui-  hours,  until  the 
middle  of  the  third  week  when  it  rose  rather  higher. 

In  a  case  kindly  communicated  to  me  by  my  friend  Dr.  Gee,  the  tem- 
perature in  a  httle  giii  under  his  care  was  103°  on  the  tii'st  day  at  2  p.m., 
and  at  10.30  p.m.  it  was  103.6°. 

In  a  case  pubhshed  by  Dr.  Ashby,  of  Manchester — a  little  gui  of  nine 
years — the  temperatui-e  was  100°  on  the  first  evening.  On  the  second 
day:  naorning,  99.4°;  evening,  101.8°.  On  the  thu'd  day:  morning, 
100.4°  ;  evening,  100.4°.     Fom'th  day  :  morning,  101°  ;  evening,  103.4°. 

From  these  three  cases  it  appeal's  that  there  may  be  great  variations  in 
the  degree  of  pp-exia  at  the  beginning  of  the  disease.  In  my  own  case 
the  temperature  reached  its  height  on  the  second  day  at  6  p.m.  ;  but  dur- 
ing the  first  two  days  the  variations  were  very  great. 

The  duration  of  tj^ihoid  fever  is  fi-om  fourteen  to  twenty-six  days  as  a 
rule.  The  temperatui-e  often  falls  in  young  subjects  at  the  end  of  a  fort- 
night ;  and  sometimes,  although  veiy  rarely,  may  become  normal  at  a  still 
earher  date.  The  possibihty  of  so  short  a  duration  for  the  fever  has  been 
doubted,  but  that  it  may  occur  is  proved  by  the  following  case. 

A  little  girl,  aged  nine  years,  was  periectly  well  on  September  14th. 
On  the  following  day,  the  loth,  she  complained  of  chilhness  and  frontal 
headache.  That  night  the  skin  was  noticed  to  be  hot,  and  for  the  next 
week  the  child  was  apathetic,  languid,  and  feveidsh,  complaining  of  head- 
ache and  abdominal  pain.  She  did  not  vomit,  and  there  was  no  bleeding 
from  the  nose.  The  child  was  seen  on  the  22d.  Her  temperature  was 
then  102°,  and  a  rose-spot  was  noticed  on  the  abdomen  by  the  house 
surgeon.  On  the  23d  (ninth  day)  she  was  admitted  into  the  hosj)ital. 
The  abdomen  was  then  moderately  distended  ;  the  spleen  could  be  felt  two 
fingers'-breadth  below  the  ribs  ;  no  s^Dots  were  to  be  seen  ;  the  temperature 
in  the  evening  was  102.6°. 


ENTEEIO   FEVER — PERFOEATIOTT,  81 

After  tHs  date  the  temperature  was  never  higher  than  99°  and  a  fraction  ; 
the  child  looked  and  expressed  herseK  as  weU  ;  the  spleen  quickly  retired 
under  the  ribs  ;  the  appetite  was  good,  and  the  patient  complained  much 
at  being  restricted  to  hquid  food.  On  October  5th,  the  temperatui^e  having 
been  normal  for  twelve  days  (with  the  exception  that  on  one  occasion,  in 
the  coui'se  of  September  27th,  it  rose  to  100.3''),  and  subnormal  for  six, 
the  child  was  x^ut  on  ordinary  diet.  Two  days  afterwards  the  temperature 
rose  to  102^,  the  sx^leen  began  to  enlarge ;  rose  spots  appeared  on  the  ab- 
domen ;  and  the  j)atient  passed  through  a  well-marked  relapse  of  typhoid 
fever  which  lasted  the  usual  nine  days. 

In  this  case  the  early  cessation  of  the  jDyi-exia  seemed  to  exclude  typhoid 
fever ;  and  as  the  temperature  continued  low,  a  meat  diet  was  allowed 
under  the  idea  that  our  first  imjDression  of  the  iUness  had  been  a  mistaken 
one.  The  prompt  occun-ence  of  a  typical  relapse,  however,  at  once  re- 
moved our  doubts  as  to  the  nature  of  the  primary  attack. 

In  some  cases  the  temperatui-e  remains  high  after  the  usual  time  of  fall- 
ing at  the  end  of  the  third  week.  In  many  cases  this  is  due  to  progressive 
ulcerative  enteritis.  Indeed,  Dr.  Gree  lays  it  down  as  a  rule  that  when 
pyrexia  and  enteric  symptoms  last  longer  than  twenty-six  days  this  is  the 
cause  of  the  prolongation  of  the  disease.  He  also  suggests  that  "subin- 
trant  relapse  "  may  be  an  occasional  agent  in  producing  the  same  result. 

Death  from  the  intensity  of  the  general  disease,  so  common  in  the 
adult,  is  very  rare  in  early  life.  In  very  exceptional  cases,  however,  the 
diarrhoea  may  be  excessive  ;  the  temperature  may  rise  to  a  high  level ;  the 
pulse  may  be  frequent,  feeble  and  dicrotous ;  the  abdomen  may  he 
swoUen  and  tympanitic ;  the  child  is  deliiious,  then  comatose,  and  dies 
with  a  temperatm-e  of  108^  or  109°.  Still,  although  this  ij]ie  of  the 
disease  is  occasionally  met  with  in  the  child,  it  must  happen  to  few  prac- 
titioners to  meet  with  such  cases.  When  childi-en  die  from  typhoid  fever, 
they  die  almost  invariably  from  perforation  of  the  bowel  and  general  peri- 
tonitis. The  rupture  occurs  in  the  floor  of  a  deep  ulcer  and  takes  place 
quite  suddenly.  It  is  followed  by  an  escape  of  gas  and  of  the  fluid  con- 
tents of  the  intestine  into  the  peritoneal  cavity.  Immediately,  the  abdo- 
men becomes  distended,  and  there  is  intense  pain  and  tenderness.  Some- 
times there  is  vomiting,  but  the  patient  in  any  case  sinks  into  a  state  of 
collapse  with  dusky  haggard  face,  cool  purple  extremities,  and  small  rapid 
pulse.  Although  the  surface  of  the  body  feels  cool,  the  internal  heat  re- 
mains high  (103-104°).  The  respiration  is  thoracic.  According  to  Me- 
meyer,  sudden  disappearance  of  the  liver  dulness,  on  account  of  that 
organ  being  separated  by  the  tympanitis  from  the  abdominal  wall,  is  one 
of  the  most  certain  signs  of  peritonitis  from  perforation  of  the  bowel. 
This  accident  does  not  often  happen  before  the  end  of  the  third  week. 
When  the  peritonitis  is  general,  it  is  almost  invariably  fatal,  and  death  is 
sometimes  preceded  by  an  attack  of  convulsions.  If  the  intestine  have 
been  previously  matted  by  local  inflammation,  rupture  of  the  floor  of  the 
ulcer  may  not  lead  to  such  serious  consequences.  In  such  a  case  when 
perforation  occm-s,  the  extravasated  contents  of  the  bowel  remain  encysted, 
and  the  resulting  peritonitis  is  hmited  to  the  neighbourhood  of  the  lesion. 
In  the  end  the  abscess  thus  formed  generally  makes  its  way  to  the  surface 
and  discharges  its  contents  at  some  point  of  the  abdominal  wall. 

Other  complications  which  give  rise  to  discomfort  or  danger  are  _: — 

inflammation  of  the  parotid  gland,  or  of  the  middle  ear,  bronchitis,  pleurisy, 

pneumonia,  and  catan-hal  pneumonia.     In  one  case — a  boy  aged  thirteen, 

Tinder  my  care  in  the  East   London  Childi-en's  Hospital — an  extensive 

6 


82  DISEASE  IN   CHILDEEN. 

plastic  pericarditis  arose  during  the  third  week  of  illness.  Bedsores 
rarely  occur  unless  the  child  is  greatly  reduced  by  protracted  illness ;  but 
boils  and  abscesses  are  not  uncommon.  Ulceration  of  the  larynx  has  been 
described,  but  must  be  very  rare.  Another  rare  complication  is  throm- 
bosis of  the  veins  of  the  lower  extremities. 

After  the  fever  has  subsided,  the  temperature  usually  remains  subnor- 
mal for  some  time.  Not  unfrequently,  however,  after  the  lapse  of  a  few 
days,  the  child  is  noticed  to  be  feverish  again.  These  secondary  pyrexias 
are  very  common.  They  may  be  due  to  a  real  relapse ;  to  the  presence 
of  some  irritant  in  the  bowel,  such  as  hardened  fecal  matter  or  undigested 
food  ;  or  to  some  febrile  complication  which  may  be  called  accidental,  as 
an  abscess. 

Keal  relapses  are  far  from  uncommon.  They  begin  after  a  variable  in- 
terval— four  or  five  days,  or  longer — and  seem  in  many  cases  to  be  deter- 
mined by  injudicious  feeding  in  the  stage  of  early  convalescence.  The 
temperature  rises  ;  the  spleen  again  enlarges  ;  fresh  spots  appear ;  and  the 
bowels  may  be  again  relaxed.  Usually  the  symptoms  are  milder  than  in 
the  primary  attack  and  last  a  shorter  time.  The  average  duration  of  a  re- 
lapse is  nine  days. 

Constipation  and  the  irritation  of  the  bowel  by  hard  fecal  masses  is  a 
common  cause  of  secondary  pyrexia.  The  temperature  usually  rises  to 
102°  or  103°,  but  may  be  higher.  When  the  irritant  has  been  removed  by 
a  copious  injection,  the  pyrexia  at  once  disappears.  These  attacks  of  tem- 
porary elevation  of  temperature  may  recur  again  and  again  in  the  course 
of  convalescence,  but  need  occasion  no  anxiety. 

Convalescence  from  typhoid  fever  is  often  tedious.  The  child  is  left 
weak  and  low,  and  nutrition  may  not  at  once  be  re-established.  It  is  a  re- 
markable fact^— to  which  attention  has  been  drawn  by  Dr.  West — that  the 
patient  is  enfeebled  intellectually  as  well  as  physically  by  his  illness.  For 
some  weeks  after  the  fever  is  over  he  may  remain  dull  and  indifferent, 
taking  little  interest  in  pursuits  and  amusements  which  formerly  delighted 
him.  A  child  of  three  or  four  years  of  age  may  seem  to  have  forgotten 
how  to  talk ;  and  the  persistence  of  this  mental  weakness  for  some  time 
after  the  strength  has  been  restored  is  often  a  cause  of  great  anxiety  to  the 
patient's  friends.  Such  anxiety  is,  however,  groundless,  for  the  return  of 
mental  tone  at  no  long  interval  may  be  confidently  predicted. 

These  cases  appear  to  be  due  sometimes  to  defective  action  of  the  kid- 
neys. In  one  case  which  came  under  my  notice  the  child  (a  boy  of  seven) 
■was  left  after  typhoid  fever  in  an  apathetic,  stupid  condition,  taking  no 
notice  of  anything,  and  never  speaking  even  to  make  known  his  natural 
wants.  He  appeared  to  be  in  a  state  of  great  weakness,  and  had  occasion- 
ally nervous  seizures  in  which  he  became  quite  stiff,  and  seemed  to  be  un- 
conscious. His  skin  was  dry  and  excessively  inelastic  ;  there  was  no  dis- 
coverable disease  of  any  of  his  organs ;  his  temperature  was  subnormal. 
At  first  he  had  a  sHght  trace  of  oedema  of  the  legs,  but  this  quickly  passed 
off.  His  urine  never  contained  albumen,  but  its  quantity  was  small.  For 
a  long  time  the  boy  passed  no  more  than  ten  or  twelve  ounces  in  the 
twenty-four  hours,  with  a  specific  gravity  of  1.015.  The  excretion  of  solid 
matter  by  the  kidneys  was  so  evidently  deficient  that  diuretics  were  or- 
dered, and  the  boy  was  forced  to  take  a  larger  quantity  of  fluid.  Under  this 
treatment  he  soon  began  to  mend  ;  his  urine  became  more  copious  with  a 
higher  density ;  the  elasticity  of  his  skin  retxirned ;  his  nervous  seizures 
ceased  ;  and  his  strength,  mental  and  bodily,  rapidly  improved. 

A  child  with  any  diathetic  taint  may  have  his  predisposition  strength- 


ENTERIC   FEVEE — DIAGISTOSIS.  83 

ened  by  his  illness.  Tuberculosis  sometimes  occurs  ;  and  scrofulous  ten- 
dencies may  receive  a  distinct  impulse. 

Diagnosis.— On  account  of  tlie  negative  character  of  the  symptoms  at 
the  beginning  of  the  illness,  enteric  fever  is  often  difficult  to  recognize  in 
the  early  stage  ;  and  even  at  a  later  period  the  nature  of  the  complaint 
must  be  sometimes  a  matter  of  doubt.  Still,  the  disease  is  one  of  such 
frequent  occurrence  that  we  should  always  remember  the  possibility  of  its 
being  present,  and  should  never  omit  in  a  doubtful  case  to  make  inquiry 
as  to  the  existence  of  the  disease  in  the  neighbourhood.  The  beginning  of 
measles,  scarlatina,  and  variola  is  sufficiently  distinctive  to  prevent  their 
l)eing  confounded  with  this  disorder,  and  moreover,  the  absence  of  the 
specific  eruptions  of  these  complaints  will  serve  for  their  exclusion.  A 
high  temperature  on  the  second  day  in  a  child  who  suffers  from  nothing 
but  an  ill-defined  malaise  is  enough  to  give  grounds  for  suspicion.  If,  as 
the  days  pass,  no  other  symptom  develops  itself,  our  suspicions  are  ma- 
terially strengthened  ;  and  when  at  the  end  of  the  week,  enlargement  of 
the  spleen  with  swelling  and  tenderness  of  the  belly  can  be  detected, 
especially  if  there  is  also  looseness  of  the  bowels,  there  is  hardly  room  for 
further  hesitation. 

Acute  tuberculosis  may  present  a  very  close  resemblance  to  enteric 
fever  in  the  child,  especially  as  we  sometimes  see  a  rose  spot  here  and 
there  on  the  bodies  of  tubercular  children  which,  except  for  being  rather 
larger  than  the  typhoid  spot,  and  perhaps  a  little  less  delicate  in  colour, 
may  be,  and  indeed  has  been,  mistaken  for  it.  In  both  tuberculosis  and 
enteric  fever  diarrhoea  may  be  a  prominent  feature  ;  in  both  there  is  fever  ; 
and  in  both  the  general  symptoms  may  be  very  indefinite.  Often,  in  these 
cases  we  cannot  decide,  but  must  wait  for  time  to  relieve  our  uncertainty. 
But  in  many  cases  we  may  venture  upon  an  opinion,  for  in  tubercu- 
losis the  absence  of  any  definite  time  of  beginning  ;  the  less  elevated  tem- 
23erature,  the  bodily  heat  being  rarely  higher  than  101°  in  the  evening  ;  the 
distressed  expression  of  the  patient ;  the  absence  of  inflation  of  the  abdo- 
men, and  the  natural  size  of  the  spleen  are  all  points  in  which  that  form  of 
illness  differs  from  ^phoid  fever,  and  may  serve  to  help  us  to  a  conclusion. 

Sometimes  enteric  fever  may  be  mistaken  for  tubercular  meningitis. 
The  illness  may  begin  with  drowsiness  and  sickness ;  the  headache  may  be 
severe  and  provoke  cries  from  the  child  such  as  are  common  in  the  intra- 
cranial inflammation  ;  the  vomiting  may  persist,  and  the  bowels  may  be 
obstinately  confined.  Still,  the  belly  is  distended,  and  has  not  the  doughy, 
flaccid  condition  of  the  parietes  so  peculiar  to  tubercular  meningitis ;  the 
pulse,  until  convalescence  begins,  is  not  slow  and  intermittent ;  the  respi- 
ration is  not  sighing ;  the  pupils  do  not  become  unequal,  and  there  is  no 
squint.  The  temperatiu'e,  too,  is  much  higher  in  the  case  of  tyj)hoid  fever, 
for  in  the  earlier  stages  of  tubercular  meningitis  the  bodily  heat  is  seldom 
greater  than  101°.  Later,  none  of  the  symptoms  of  the  third  stage  of  tuber- 
cular meningitis  can  be  discovered. 

Acute  gastric  catarrh,  accompanied  as  it  is  in  scrofulous  children  with 
pyrexia,  may  cause  some  embarrassment,  but  here  the  temperature  is  less 
high  than  in  enteric  fever,  and  does  not  undergo  the  same  alternations ; 
there  is  no  distention  of  the  abdomen,  and  no  enlargement  of  the  spleen. 
Stni,  in  many  cases,  before  the  fever  subsides  on  the  ninth  or  tenth  day, 
we  cannot  say  positively  that  we  have  not  to  do  with  the  more  serious 
disease. 

When  the  purging  is  severe  the  case  may  be  confounded  with  one  of 
inflammatory  diarrhoea,  and  it  is  possible  that  in  young  children  under 


84  DISEASE   IN   CHILDEEjST. 

three  or  four  years  of  age  the  mistake  is  often  made.  I  think,  however^ 
that  the  shorter  course  of  a  non-specific  muco-enteritis,  the  severity  of  the- 
purging  from  the  first,  the  haggard  aspect  of  the  patient,  and,  if  the  dis- 
ease last  long  enough,  the  absence  of  splenic  enlargement,  of  the  rosy  rash, 
and  of  the  signs  of  pulmonary  catarrh,  should  be  sufficient  to  furnish  a 
distinction. 

Simple  or  tubercular  ulceration  of  the  bowels  with  enlargement  of  the 
mesenteric  glands  may  be  also  mistaken  for  enteric  fever.  But  in  these 
disorders  the  temperature  is  less  elevated  than  in  typhoid  fever,  and  the 
history  of  the  illness  is  very  different.  Their  coru'se,  also,  is  very  much 
longer.  There  is,  besides,  absence  of  the  rash,  of  the  splenic  enlargement 
(unless,  as  may  happen,  there  is  tubercular  disease  of  the  spleen)  and  of 
the  signs  of  pulmonary  catarrh.  Further,  in  tubercular  ulceration  the 
limgs  are  generally  the  seat  of  consolidation  and  the  emaciation  is  extreme. 

Chronic  tubercular  peritonitis,  with  its  rough  harsh  skin,  its  pseudo- 
fluctuation,  and  the  caseous  masses  to  be  felt  on  palpation  of  the  abdomen, 
can  scarcely  be  confounded  with  enteric  fever. 

Lastly,  the  distinction  between  tj^phoid  and  typhus  fevers  is  now  suffi- 
ciently established.  In  the  latter  disease  the  onset  is  alwaj^s  abrupt,  the 
rash,  abundant  and  quite  different  in  its  appearance  from  the  rosy  typhoid 
spots,  appears  on  the  fifth  day  ;  the  face  is  dusky  ;  drowsiness  and  stupor- 
are  early  symptoms ;  and  the  end — whether  favourable  or  the  reverse — 
comes  in  a  sudden  crisis. 

Prognosis. — It  has  been  ah-eady  said  that  comparatively  few  children 
die  from  this  disease  ;  but  small  as  is  the  percentage  of  mortahty,  it  is 
greater  than  it  need  be.  This  is  partly  due  to  the  way  in  which  the 
disease  begins,  and  the  mildness  of  its  early  symptoms  making  diagnosis 
doubtful.  It  is  also  owing  in  part  to  the  character  of  the  early  symptoms, 
and  the  abuse  of  domestic  remedies.  A  child  is  found  to  be  poorly ;  he 
vomits  and  complains  of  headache.  Immediately  he  is  treated  to  a  dose 
of  castor-oil  or  other  aperient ;  and  as  the  symptoms  are  not  found  to 
be  relieved  by  this  measure,  the  dose  is  repeated,  perhaps  several  times. 
There  is  no  doubt  that  such  treatment  is  excessively  injurious  ;  and  in. 
hospital  practice  the  cases  which  terminate  fatally  generally  have  a  history 
of  active  purgation  having  been  adopted  before  admission. 

However  severe  the  symptoms  may  be,  we  may  look  forward  hoj)efully 
to  the  issue  provided  perforation  has  not  occurred.  Children  resiDond 
well  to  stimulants  in  tyjDhoid  fever  ;  and  a  patient  who  is  seen  stupid 
and  drowsy  and  profoundly  depressed  on  one  visit,  may  present  a  veiy 
different  appearance  on  the  next  under  the  fi'ee  use  of  brandy.  I  think 
even  muscular  tremors  have  not  the  same  unfavourable  meaning  in  the 
child  that  they  have  in  the  adult.  Still,  if  the  tongue  quivers  when  pro- 
truded, the  lower  jaw  trembles  when  the  mouth  is  open,  and  general 
tremulousness  of  movement  is  pronounced,  we  have  reason  to  fear  the 
presence  of  a  deep  ulcerative  lesion  in  the  intestine.  Our  apprehensions 
are  strengthened  if  at  the  same  time  the  belly  is  much  distended,  and  the 
temperature  remains  persistently  elevated  after  the  end  of  the  thuxl  week.. 
In  such  a  case  the  danger  of  perforation  is  imminent. 

If  perforation  take  place,  the  prognosis  is  most  grave  ;  but  even  in 
this  strait  death  is  not  absolutely  certain.  If  the  collapse  which  foUows 
the  extravasation  be  quickly  recovered  fi'om,  even  although  considerable 
tympanitis,  pain,  and  tenderness  remain,  we  may  hope  that  the  peritonitis 
has  been  localised  by  intestinal  adhesions,  and  that  further  improvement 
may  take  place. 


ENTEEIC  FEVER — TREATMENT.  85 

Treatment. — In  every  case  of  typhoid  fever,  if  there  is  any  reason  to 
suppose  that  the  disease  has  been  contracted  in  the  house,  the  drains 
should  be  thoroughly  examined  at  the  earliest  opportunity,  and  every  care 
must  be  taken  to  prevent  the  entrance  of  sewer-gas  into  the  passages. 
All  soil-pipes  should  be  ventilated :  waste-pipes  should  be  cut  off  from 
direct  communication  with  the  sewers ;  cisterns  supplying  water  for 
drinking  and  cooking  should  be  entirely  separated  from  those  whose  pur- 
pose is  merely  sanitary ;  and  the  water  itself — unless  its  purity  be  above 
susj)icion — should  not  be  drunk  without  having  previously  been  boiled 
and  filtered. 

The  treatment  of  typhoid  fever  consists  mainly  in  careful  and  judicious 
nursing.  Sir  William  Jenner  has  insisted  strongly  upon  the  absolute 
necessity  in  this  complaint  of  perfect  rest.  The  child  should  be  confined 
to  bed  at  once,  and  if  the  attack  has  occurred  at  a  distance  from  his  home, 
it  is  better  that  he  should  remain  where  he  is,  than  run  the  risk  of  in- 
creasing the  severity  of  his  illness  by  the  fatigues  of  a  removal.  Fatigue 
not  only  exhausts  nerve-power,  which  is  already  reduced  by  the  fever,  but 
it  also  increases  destruction  of  tissue  at  the  same  time  that  it  checks  elimi- 
nation by  the  excretory  organs.  The  bedroom  should  be  a  large  one,  and 
the  air  must  be  kept  as  pure  as  possible  by  judicious  ventilation.  Its 
temperature  should  not  be  allowed  to  rise  above  65°.  The  patient  should 
be  lightly  covered  and  not  overloaded  with  bedclothes.  There  is,  how- 
ever, one  precaution  which  it  is  expedient  to  take.  As  in  all  cases  where 
the  mucous  membrane  of  the  bowels  is  the  seat  of  catarrh,  flannel  in  the 
shape  of  a  flannel  bandage  should  be  applied  round  the  belly  so  as  to 
avoid  the  risk  of  chill.  All  discharges  from  the  body  must  be  at  once 
disinfected  before  being  removed  from  the  room,  and  linen,  etc.,  soiled  by 
■such  discharges  must  be  su.bjected  to  the  same  disinfecting  process  before 
being  washed.  If  there  be  reason  to  suspect  the  purity  of  the  water-sup- 
j)ly,  none  should  be  used  for  drinking  purposes  without  previous  boiling 
and  filtering.  This,  however,  the  child  may  be  allowed  to  drink  without 
.stint,  provided  too  large  a  quantity  be  not  taken  at  once.  A  free  supply 
t)f  water  assists  the  depurating  action  of  the  skin,  kidneys,  and  lungs  ;  but 
distention  of  the  stomach  by  too  much  fluid  is  provocative  of  nausea  and 
flatulence.  For  this  reason  effervescing  drinks  are  to  be  avoided  ;  they 
are  apt  to  distend  the  stomach  and  cause  uneasiness. 

The  question  of  diet  is  a  very  important  one.  The  old  plan  of  "  starving 
the  fever  "  and  reducing  the  patient  has  been  fortunately  abandoned,  but 
we  must  not  fl}'  to  the  opposite  extreme  and  overload  the  stomach  with 
food  in  the  hope  of  supporting  the  strength,  however  digestible  and  well 
selected  the  food  may  be.  Farinaceous  matters,  on  account  of  their  ten- 
dency to  ferment  and  foi-m  acid,  are  better  avoided.  Fruit  for  the  same 
reason  is  out  of  the  question.  It  is  better  to  restrict  the  diet  to  meat 
broths  made  fresh  in  the  house,  and  to  milk.  The  broths  may  be  flavoured 
with  vegetables,  but  must  be  carefully  strained.  The  milk  should  be  di- 
luted with  an  equal  quantity  of  barley-water,  so  as  to  split  up  the  curd  and 
prevent  its  coagulating  in  the  stomach  in  large  lumps.  Masses  of  hard 
curd  are  a  frequent  source  of  irritation,  and  may  excite  restlessness  and  ab- 
dominal pains.  They  may  also,  perhaps,  increase  the  diarrhoea.  The 
quantity  of  food  to  be  given  at  one  time  should  never  be  left  to  the  dis- 
cretion of  the  attendants.  Nourishment  should  be  administered  in  pre- 
scribed doses  at  regnlar  intervals — the  quantity  and  the  length  of  the  in- 
tervals to  be  decided  by  the  age  of  the  patient  and  the  facihty  with  which 
the  meal  can  be  digested.     Nausea,  restlessness,  excitement  of  pulse,  in- 


86  DISEASE  IlSr   CHILDRElSr. 

crease  of  fever,  and  flushing  of  face,  are  signs  that  the  digestive  organs  are 
being  taxed  beyond  their  powers. 

The  question  of  stimulation  is  closely  allied  to  that  of  food.  Stimu- 
lants must  not  be  given  too  early.  They  are  useful  to  strengthen  the  ac- 
tion of  the  heart  and  increase  nerve-energy,  but  are  seldom  required  before 
the  end  of  the  second  or  beginning  of  the  third  week  of  the  disease.  Even 
then,  they  should  be  only  given  in  severe  cases  where  the  heart's  action 
gives  signs  of  failing,  and  there  is  marked  delirium  or  great  muscular  pros- 
tration with  tremor.  Tremor,  "  out  of  all  proportion  to  other  signs  of 
nervous  prostration,"  is,  in  the  opinion  of  Sir  William  Jenner,  evidence 
of  deep  destruction  of  the  bowel.  In  these  cases  alcohol  is  of  the  utmost 
value.  The  signs  connected  with  the  heart  which  may  be  taken  to  indicate 
the  necessity  for  stimulation  are  diminution  or  suppression  of  the  impulse 
with  feebleness  of  the  first  sound.  The  effect  of  stimulation  should  be 
carefully  watched.  If  the  fever  diminish,  the  tongue  and  skin  get  or  re- 
main moist,  the  pulse  and  respiration  become  slower  and  fuUer,  and  the 
mind  clearer,  we  may  know  that  we  have  benefited  our  patient.  If,  on  the 
contrary,  the  temperature  rise,  the  heart's  action  become  feebler  and  more 
fi-equent,  the  delirium  increase,  and  the  child  get  restless  with  inabihty  to 
sleep  ;  or  if  he  become  duller  and  seem  sinking  into  a  comatose  state,  we 
may  conclude  that  alcohol  is  acting  injuriously,  and  that  it  must  be  discon- 
tinued or  given  in  smaller  quantities. 

In  tj^Dhoid  fever,  as  in  all  other  febrile  diseases,  it  is  important  to 
watch  the  temperattu-e  and  regulate  it.  If,  for  instance,  with  a  tempera- 
ture of  105°,  we  find  restlessness  and  excitement  with  wakefulness,  the 
child  should  be  sponged  over  the  whole  body  with  tepid  or  cold  water. 
This  lessens  fever,  cahns  irritability,  and  induces  sleejD.  More  than  tepid 
or  cold  sponging  is  seldom  necessary.  If,  however,  the  temperature  be 
not  appreciably  lowered  by  the  sponging  or  rise  again  immediately,  the 
child  maj'  be  placed  gently  in  a  bath  containing  water  at  70°,  and  be  kept 
immersed  for  ten,  fifteen,  or  twenty  minutes.  It  is  well  to  continue  the 
bath  until  distinct  shivering  has  been  produced.  The  child  must  be  then, 
removed,  wdped  dry,  and  returned  to  his  bed.  A  stimulant  may  be  given, 
at  this  time  if  thought  desirable.  The  cool  bath  should  not  be  used  unless^ 
there  is  a  real  necessity  for  it.  Children  can  bear  a  continued  high  tem- 
perature better  than  older  persons  ;  and  if  there  is  a  daily  remission,  as 
occurs  in  most  cases,  mere  sponging  will  do  all  that  is  required. 

Delirium  is  scarcely  sufficiently  violent  in  children  to  require  treat- 
ment— at  any  rate  in  ordinary  cases,  and  headache  is  seldom  a  trouble- 
some symptom.  If  it  should  be  so,  it  is  usually  reheved  by  cold  applica- 
tions. Slee]3lessness  may  be  generally  relieved  by  the  tepid  sponging- 
above  referred  to.  If  necessary,  a  draught  containing  bromide  of  potas- 
sium in  combination  with  chloral  may  be  given. 

DiarrhcBa  may  sometimes  require  remedies.  In  every  case  where  the 
stools  are  too  frequent  and  watery  we  should  examine  them  for  curd  of 
milk.  If  this  be  present,  the  amount  of  milk  taken  at  one  time  must  be 
reduced.  We  should  also  take  care  that  the  child  does  not  drink  fluid  in 
excess,  and  if  necessary  his  drink  must  be  given  to  him  in  smaller  quan- 
tities. When  drugs  are  required  to  arrest  the  purging,  chalk  and  catechu 
should  be  given  if  the  motions  are  frothy.  If  they  are  strongly  alkahne, 
dilute  sulphuric  acid  is  most  useful.  Li  the  later  period,  when  there  is 
tdceration  of  the  bowel,  bismuth  in  large  doses  is  indicated.  Hsemorrhage 
from  the  bowels  is  a  comparatively  rare  sjanptom  in  the  child  and  seldom 
requires  treatment  by  drugs.    If  necessary,  however,  gaUic  acid  and  dilute-. 


ENTERIC  FEVER — TREATMENT.  87 

sulpliurie  acid  may  be  administered  with  small  doses  of  opium.  In  such 
a  case  the  child  should  on  no  account  be  allowed  to  raise  himself  from 
the  recumbent  posture  even  to  reheve  the  bladder  or  the  bowels.  It  is 
well  also  to  give  him  his  food  in  small  quantities  and  in  a  concentrated 
form.  Strong  beef-essence,  well  iced,  and  good  meat  jelly  should  be  em- 
ployed ;  and  but  little  milk  should  be  allowed,  for  fear  of  irritating  the 
intestine  with  lumps  of  ciird. 

If  perforation  and  peritonitis  occur,  opium  should  be  given  in  small 
doses,  but  frequently,  so  as  to  produce  some  of  the  early  physiological 
effects  of  the  drug,  such  as  drowsiness  and  tendency  to  contraction  of 
pupils.  In  my  experience  opium  is  in  such  cases  of  small  value  unless 
pushed  to  this  extent.  The  belly  should  be  also  smeared  with  an  oint- 
ment composed  of  equal  parts  of  extract  of  belladonna  and  glycerine,  and 
be  kept  covered  with  hot  linseed  meal  poultices  frequently  renewed.  The 
food  in  these  cases  also  must  be  concentrated  and  given  frequently  in  small 
quantities.     Brandy  and  egg  will  be  required  to  sustain  the  strength. 

Daring  the  period  of  convalescence  careful  feeding  is  still  necessary, 
for  errors  in  diet  at  this  time  are  a  frequent  cause  of  relapse  in  the  fever. 
I  have  always  made  it  a  rule  to  allow  no  solid  food  until  ten  days  have 
passed  after  the  final  faU  of  temperature.  But  even  then  the  usual  diet 
of  health  should  be  only  slowly  returned  to. 

In  order  to  prevent  relapses  Immerman  recommends,  in  addition  to 
the  utmost  vigilance  with  regard  to  diet,  the  daily  administration  of  sali- 
cylate of  soda  in  full  doses;  beginning  directly  the  fever  subsides,  and 
continuing  the  use  of  the  drug  for  ten  or  twelve  days.  The  after  aneemia 
and  weakness  must  be  combated  by  iron  and  good  food.  Change  of  air 
to  a  dry  bracing  place  or  to  the  seaside  is  very  useful. 


CHAPTEE   X. 

DIPHTHERIA. 

Diphtheria  is  an  acute  contagious  disease  whicli,  on  account  of  its  pre- 
valence, its  gravity,  its  consequences,  and  the  frequency  with  which  it  is 
met  with  in  the  child,  takes  a  prominent  place  amongst  the  disorders  of 
early  life.  The  disease  induces  gTeat  anaemia  and  prostration,  and  is 
characterized  anatomically  by  inflammation  of  various  mucous  surfaces  and 
the  formation  on  them  of  a  more  or  less  tough  and  leathery  false  mem- 
brane. The  inflammation  often  spreads  to  some  distance  from  its  point 
of  origin,  but  at  fii'st  is  usually  confined  to  a  comparatively  limited  area. 
The  seat  varies  in  different  cases  ;  and  the  sjmiptoms  are  therefore  subject 
to  great  variety  according  to  the  paii  in  which  the  chief  local  expression 
of  the  disease  occurs. 

When  the  inflammatory  process  attacks  the  larynx  the  malady  is  called 
membranous  croup,  and  this  was  long  held  to  be  a  distinct  affection. 
Whether  all  cases  of  membranous  croup  are  diphtheritic  in  their  nature 
— whether  a  false  membrane  can  be  developed  in  the  air-passages  apart 
from  the  diphtheritic  poison — is  a  question  upon  which  pathologists  in  this 
country  are  still  divided.  That  membranous  croup  arises  in  many  cases 
from  this  cause  is  undeniable.  Instances  have  been  met  with  in  which  diph- 
theria has  attacked  the  pharynx  in  some  members  of  a  family  and  the 
larynx  in  others.  Thus,  Dr.  Woodman  found  membranous  laiyngitis  in 
two  infants,  aged  respectively  eighteen  months  and  two  months,  while 
others  of  the  family  suffered  from  false  membrane  in  the  mouth  and 
pharynx.  ■  Dr.  Wilks  has  seen  in  different  inmates  of  the  same  house  the 
disease  remain  confined  to  the  throat,  or  spread  thence  to  the  larynx,  or 
begin  in  the  larynx  ;  and  Trousseau  refers  to  a  case  reiDoried  by  Dr.  A. 
Guerard  in  which  a  Httle  girl  died  of  laryngeal  croujD,  and  other  members 
of  the  family  suffered  immediately  afterwards  fi'om  pseudo-membranous 
pharyngitis.  Moreover,  it  is  admitted  by  the  best  authorities  that  the 
laryngeal  false  membrane  has  exactly  the  same  anatomical  characters, 
whether  it  be  due  to  the  spread  of  a  pharyngeal  diphtheria  or  arise  pri- 
marily as  a  case  of  membranous  croup. 

Advocates  of  the  essential  difference  between  the  two  forms  of  illness 
maintain  that  the  character  of  the  two  diseases  is  not  the  same.  Croup, 
they  say,  is  a  sthenic  disease,  while  diphtheria  is  asthenic.  But  some 
cases  of  croup  are  accompanied  by  severe  constitutional  depression  and  all 
the  signs  of  profound  general  disease  ;  while  diphtheria  is  not  invariably 
accompanied  by  symptoms  of  prostration.  Indeed,  one  of  the  peculiari- 
ties of  this  affection  is  the  occur-rence  sometimes  of  marked  paralysis  after 
an  attack  of  sore  throat  so  mild  as  to  be  almost  overlooked. 

Secondly,  it  is  pointed  out  that  in  diphtheria  the  glands  at  the  angles 
of  the  jaw  are  invariably  enlarged,  while  in  membranous  croup  they  are 
little  if  at  all  affected.     But  the  larvnx  has  Httle  connection  with  the  su- 


* 

DIPHTHERIA   AISTD   CEOUP.  89 

perficial  cervical  glands.  As  Dr.  Morell  Mackenzie  has  pointed  out,  in 
cancer  of  the  larynx  the  cervical  glands  are  not  enlarged,  while  if  the 
maUgnant  disease  affect  the  pharynx  these  glands  are  always  involved. 

Thirdly,  the  contagiousness  of  diphtheria  is  insisted  upon,  while  mem- 
l)ranous  croup  is  said  not  to  be  communicable  by  one  child  to  another. 
But  the  risk  of  infection  is  in  direct  proportion  to  the  amount  of  exuda- 
tion, and  the  readiness  with  which  the  membrane  can  be  detached  and 
-dispersed.  In  the  glottis  the  membrane  is  very  firmly  adherent ;  in  the 
pharynx  its  connections  are  much  looser,  and  it  is  much  more  easily 
separable  from  the  mucous  surfaces.  Moreover,  as  Sir  William  Jenner  has 
observed,  the  conditions  in  which  the  patient  is  placed  vary  gTeatly  in  the 
iwo  cases.  A  child  with  diphtheria  in  its  early  stage  is  up  and  about,  kisses 
his  brothers  and  sisters,  and  has  every  opportunity  of  convening  the  dis- 
ease to  them.  A  patient  with  membranous  croup  is  kept  in  bed  apart  from 
the  other  children  and  carefully  tended.  Still,  there  is  strong  evidence 
that,  in  sj)ite  of  these  hindrances  to  its  ready  communication,  membranous 
croup  may  be  conveyed  from  one  child  to  another.  Dr.  Trend  states  that  he 
has  seen  the  laryngeal  disease  in  more  than  one  child  of  a  family  at  the 
«ame  time.  Dr.  Wilks  believes  that  he  has  seen  diphtheria  begin  in  the 
house  as  a  case  of  supposed  membranous  croup,  and  afterwards  attack 
others  of  the  inmates  in  the  form  of  diphtheritic  pharyngitis.  Dr.  A. 
Guerard's  case,  already  referred  to,  is  another  instance  of  the  contagious- 
ness and  interchangeability  of  the  two  varieties. 

Fourthly,  albuminuria,  which  is  common  in  diphtheria,  is  said  to  be 
rare  in  membranous  croup.  But  this  is  not  altogether  the  fact.  More- 
over, albumen  does  not  always  appear  in  the  lu'ine  at  the  beginning  of  an 
attack  of  diphtheria,  but  may  be  delayed  for  several  days.  Now  the  dura- 
tion of  fatal  cases  of  croup  is  often  terribly  short ;  so  that  the  patient  may 
die  before  the  albuminuria  has  had  time  to  occur. 

Lastly,  paralysis  is  a  not  uncommon  sequel  of  diphtheria,  while  in 
membranous  croup  it  is  very  rare.  But  it  must  be  remembered  that  true 
membranous  croup  is  an  excessively  fatal  disease  and  comparatively  few 
cases  recover.  Even  as  a  consequence  of  diphtheria  the  occurrence  of  par- 
alysis is  variable  in  different  epidemics  ;  and  taking  the  milder  cases  with 
the  severer,  the  proportion  has  been  estimated  by  Dr.  Greenfield  at  no 
more  than  one  in  twelve.  In  convalescents  from  membranous  croup  the 
p)roportion  who  are  likely  to  suffer  from  paralysis  would,  therefore,  under 
any  circumstances  be  very  small. 

From  consideration  of  the  above  facts  and  arguments  the  only  conclu- 
sion to  be  drawn  is  that  a  large  projoortion  of  cases  of  membranous  croup 
are  cases  of  laryngeal  diphtheria.  It  does  not,  however,  follow  that  mem- 
l)ranous  laryngitis  is  never  due  to  any  other  cause  than  the  diphtheritic 
3)oison.  The  child's  larynx  is  especially  prone  to  membranous  inflammation  ; 
■and  if,  as  has  been  positively  stated,  a  true  false  membrane  may  be  set 
Tip  by  burns,  scalds,  and  other  ii-ritants  to  the  air-passages,  it  is  possible 
that  the  disease  may  occasionally  occur  independently  of  the  diphtheritic 
varus. 

Diphtheria  is  met  with  both  as  an  epidemic  and  as  an  endemic  disease, 
and  varies  much  in  character  and  severity  at  different  times  and  in  differ- 
ent locahties.  It  may  attack  children  who  are  apparently  in  robust  health, 
may  arise  in  cachectic  subjects,  or  appear  as  a  sequel  of  severe  general  dis- 
ease. Like  typhoid  fever  the  disorder  is  apt  to  occur  more  than  once  in 
the  same  individual,  for  the  protection  it  affords  against  a  reciu-rence  is 
by  no  means  complete.     Sometimes  the  second  illness  may  be  more  severe 


90  DISEASE  IN   CHILDEElSr. 

than  tlie  first,  for  a  child  who  has  passed  safely  through  one  attack  may 
succumb  to  a  second. 

Gaumtion. — On  account  of  the  susceptibility  to  diphtheria  in  early  Hfe, 
childhood  may  be  considered  to  be  one  of  the  predisposing  causes  of  the 
malady.  Infants  xinder  twelve  months  of  age  are  not  often  attacked  ;  but 
after  that  age  and  up  to  the  fifth  or  sixth  year  the  disease  is  frequently 
met  with.  After  the  sixth  year  it  again  becomes  less  common,  and  is  com- 
paratively rare  in  the  adult.  Besides  this  natural  susceptibility,  there  is 
probably  in  many  cases  a  special  susceptibility  inherent  in  the  constitution 
of  the  patient.  Sometimes  whole  families  are  cut  off  during  an  epidemic 
of  the  distemper.  Sometimes  successive  children  of  the  same  parents  fall 
victims  to  the  disease  at  vai'ious  times  and  in  different  places  ;  and  in  many 
cases  this  iinfortunate  predisposition  appears  to  be  a  hereditary  defect. 
Besides  these  general  causes,  special  delicacy  of  the  thi'oat  may  render  the 
child  more  sensitive  to  the  diphtheritic  poison,  inchning  him  to  take  the 
disease  where  a  stronger  subject  would  escape  altogether.  Also  the  pres- 
ence of  a  catan-hal  condition  of  the  fauces  at  the  time  of  exposure  to  the 
unhealthy  influence  increases  the  Hkelihood  of  infection.  The  scrofulous 
constitution  has  been  said  to  induce  a  susceptibility  to  the  diphtheritic 
virus  ;  and  there  is  no  doubt  that  the  subjects  of  this  diathesis  are,  as  a 
rule,  keenly  sensitive  to  all  forms  of  zymotic  poison. 

Cold  and  moisture  appear  to  have  some  influence  in  quickening  the  ac- 
tivity of  the  contagious  principle,  for  the  disease  is  common  in  country  dis- 
tricts, especially  in  damp  places,  and  is  more  prevalent  during  the  winter 
months  than  at  any  other  period  of  the  year. 

With  regard  to  the  exciting  causes  :  There  can  be  no  question  as  to  the 
highly  poisonous  nature  of  the  exudation  from  the  affected  surfaces,  for 
the  discharges  have  often  communicated  the  disease  by  coming  into  contact 
with  a  healthy  mucous  membrane.  The  virus  may,  however,  be  also  con- 
veyed by  more  subtle  emanations  from  the  affected  person  ;  and  it  is  be- 
heved  that  the  contagious  principle  may  be  carried  to  a  distance  in  the 
clothes  of  the  patient  himself  after  convalescence,  or  in  the  dress  of  a 
nurse  who  has  not  herself  suffei'ed  from  the  disorder.  Indeed,  aU  the  sur- 
roundings of  the  patient  appear  for  some  time  to  be  capable  of  communi- 
cating the  disease.  It  is  even  stated  that  in  certain  cases  a  convalescent 
may  be  still  the  channel  through  which  the  diphtheritic  virus  is  conveyed  to 
exceptionally  susceptible  subjects,  although  ajDeriodof  months  has  elajDsed 
since  recovery  fi'om  the  disorder  ;  but  in  such  a  case  it  would  be  difficult  to 
exclude  other  and  more  recent  sources  of  infection. 

The  poison  may  be  di'awn  into  the  lungs  with  the  air  or  swallowed  in 
contaminated  water  ;  but  miich  uncertainty  exists  vdth  regard  to  the  laws 
which  govern  the  transmission  of  the  infective  matter.  Old  cesspools  and 
drains  appear  to  preserve  the  contagium  for  a  long  time  in  a  state  of  active 
virulence,  but  there  is  no  pi-oof  that  the  poison  can  be  generated  spontane- 
ously from  ordinary  filth.  The  distemper  may  originate  in  a  district 
under  one  set  of  conditions  and  be  distributed  under  other  and  different 
conditions.  There  is  no  doubt  that  insanitary  surroundings  tend  to  favour 
the  spread  of  the  disease  ;  still  it  is  probable  that  other  influences  also 
regulate  the  diffusion  of  the  infection  ;  for  when  an  outbreak  occui's  in  any 
district,  it  is  not  always  in  the  j)Oorest  and  least  cleanly  locahties — in  parts, 
that  is,  where  the  disease  would  be  expected  to  be  most  active — that  the 
largest  number  of  cases  occurs. 

In  many  outbreaks  certain  faulty  conditions,  such  as  polluted  water- 
supply,  long  standing  accumulation  of  excrementitious  matters,  and  imper- 


DIPHTHEEIA — CAUSATION — MOEBID   ANATOMY.  91 

feet  sewerage  and  drainage  generally,  are  found  to  be  common  to  all  tlie 
dwellings  in  which  the  disease  appears.  These  sanitary  deficiencies  are 
then  held  to  furnish  an  explanation  of  the  source  of  the  infection.  In  other 
cases  no  such  common  conditions  can  be  discovered,  and  the  origin  of  the 
outbreak  is  less  easy  to  account  for.  This  was  the  case  in  an  epidemic  of 
diphtheria  which  occurred  at  King's  Lynn,  and  was  reported  on  by  Dr. 
Airy.  Here  personal  conveyance  of  the  disease  was  positively  excluded  in 
the  majority  of  cases.  The  milk  was  not  at  fault.  The  water-supply,  the 
system  of  drainage,  and  the  method  of  disposal  of  the  excrement  were  in- 
sufficient, either  singly  or  together,  to  explain  the  distribution  of  the  infec- 
tion. It  was,  however,  noticed  that  excavations  had  been  in  progress  in 
the  mud  of  the  ancient  liver-bed  and  of  a  creek  which  had  once  been  a  sewer- 
in  connection  with  the  town.  Dr.  Airy  suggests  that  by  this  means  "  long- 
buried  germs  of  some  indigenous  diphtheria,  causing  microzymes,"  may 
have  been  disengaged  ;  and  that  these  carried  amongst  the  inhabitants, 
and  aided  by  season  and  atmosphere,  may  have  given  rise  to  the  out- 
break. 

Diphtheria  is  no  doubt  the  consequence  of  a  specific  poison,  however 
this  may  originate.  The  essence  of  the  disease  has  been  attributed  ta 
spherical  bacteria  (micrococci),  which  have  been  discovered  swarming  in  the 
false  membranes  and  exudations  from  the  inflamed  mucous  surfaces ;  but 
as  similar  bacteria  have  been  found  in  the  secretions  thrown  out  by  ordi- 
nary non-specific  stomatitis,  too  much  importance  must  not  be  attributed 
to  the  presence  of  these  organisms.  The  real  natui-e  of  the  viinis  has  yet 
to  be  discovered.  The  disease  with  which  diphtheria  has  the  closest  affin- 
ity apjDears  to  be  scarlatina.  Epidemics  of  the  two  disorders  are  frequently 
seen  to  prevail  in  the  same  neighbourhood  at  the  same  time,  and  it  was  once 
supposed  that  the  exciting  causes  of  the  two  diseases  were  the  same.  It  is 
now,  however,  acknowledged  that  they  have  no  mutually  protective  power  ; 
and  there  is  no  evidence  that  the  contagion  of  diphtheria  has  ever  given 
rise  to  scarlatina. 

Morbid  Anatomy. — "When  the  pharynx  is  examined  the  changes  found 
on  the  inflamed  mucous  membrane  are  as  follows  :  the  surface  becomes 
hypersemic  and  swollen,  and  after  a  few  hours  is  covered  with  a  whitish  or 
yellowish  layer  which  adheres  closely  to  the  mucous  membrane  beneath  it, 
fitting  accurately  into  every  depression  of  the  surface.  The  layer  when 
first  formed  cannot  be  removed  ;  but  as  it  increases  in  extent  and  thick- 
ness, it  gradually  becomes  tougher,  and  can  then  be  peeled  off  the  surface 
to  which  it  adheres.  Later,  it  begins  to  loosen  and  may  separate  si^on- 
taneously.  When  uncovered  the  mucous  membrane  may  be  found  to  be 
reddened  and  thickened,  and  if  the  inflammation  has  been  severe,  raw-look- 
ing or  even  ulcerated. 

On  examination  of  the  false  membrane,  it  is  found  to  present  to  the 
naked  eye  the  appearance  of  coagulated  fibrine  ;  but  under  the  microscope 
is  seen  to  consist  of  prohf erated  epithehal  cells  which  are  fused  together  into 
a  network.  These  cells  are  cloudy  from  a  peculiar  degeneration  of  their 
protoplasm.  A  vertical  section  of  the  layer  shows  the  iindermost  cells 
to  be  much  smaller  than  those  at  the  surface,  and  in  a  far  less  advanced 
stage  of  degeneration.  ]\Iinute  extravasations  of  blood  are  also  scattered 
through  the  substance  of  the  layer.  If  the  vertical  section  be  made  in  situ 
and  be  carried  down  thi'ough  the  mucous  membrane,  it  will  be  seen  that 
the  exuded  layer  is  seated  directly  upon  the  basement  membrane,  taking 
the  place  of  the  ordinary  epithelial  coating.  When  the  morbid  process- 
comes  to  an  end,  degeneration  ceases  ;  a  httle  purulent  matter,  formed  by 


92  DISEASE   IN   CHILDEEN. 

unaltered  new  cells  mixed  with  serum,  appears  between  the  mucous  surface 
and  the  false  membrane  covering  it,  and  the  latter  is  detached. 

In  the  larynx  the  mucous  membrane  is  inflamed  and  swollen,  and  a 
fibrinous  exudation  is  thrown  out  between  the  basement  membrane  and  the 
epithelial  covering.  This  on  examination  can  be  separated  into  layers  con- 
sisting, according  to  Rindfleisch,  of  alternating  strata  of  corpuscular  ele- 
ments (leucocytes)  and  of  fibrine.  The  superficial  epithelial  layer  very 
quickly  disappears.  The  micrococci,  which  are  found  in  immense  numbers 
in  the  false  membrane,  have  been  already  referred  to.  According  to  Senator, 
these  organisms  are  common  to  aU  forms  of  stomatitis,  and  are  probably 
identical  with  the  spores  of  the  leptothrix  buccalis. 

The  consistence  of  the  false  membrane  varies  in  different  cases.  It  is 
often  tough  and  tenacious,  es^DeciaUy  in  the  air-passages  ;  but  sometimes  is 
very  soft  and  pultaceous.  The  latter  condition  is  common  when  the  false 
membrane  occupies  the  pharynx  in  cases  accompanied  by  severe  constitu- 
tional symptoms  and  great  bodily  prostration.  The  more  usual  seats  of 
the  false  membrane  are  the  tonsils,  uvula,  soft  palate  and  back  of  the 
pharynx  ;  the  nasal  passages  ;  the  larynx  and  trachea.  Less  commonly  it 
is  found  on  the  conjunctiva  ;  at  the  borders  of  the  anus,  and  in  girls  of  the 
vagina.  Sometimes  it  appears  on  wounds  of  the  skin.  The  mucous  mem- 
brane is  usually,  as  has  been  said,  congested  and  swollen.  It  is  very  irritable 
and  bleeds  easily.  Sometimes  there  is  superficial  ulceration,  and  in  rare 
■cases  the  ulceration  extends  deeply,  and  sloughing  of  the  tissues  may  occur. 
Small  ulcerations  about  the  edges  of  the  glottis  are  especially  common  in 
cases  where  the  inflammation  occupies  the  larynx.  The  cer^dcal  glands  are 
swollen  from  rapid  proliferation  of  smaU  round  ceUs,  and  the  surrounding 
tissues  are  infiltrated  with  serum  containing  scattered  pus-cells. 

Besides  these  local  pathological  changes,  other  organs  of  the  body  are 
often  affected.     Thus  : — 

The  lungs  may  be  the  seat  of  lobular  pneumonia  or  collapse  ;  and  the 
air-]3assages  are  sometimes  lined  with  false  membrane  as  far  as  their  smaller 
branches. 

The  heart,  although  itself  showing  no  signs  of  disease,  may  have  it? 
right  ventricle  filled  with  a  colourless  ante-mortem  clot  which  extends  into 
the  ventricle.  It  is  sometimes  stated  that  the  lining  membrane  may  be  the 
seat  of  endocarditis  ;  but  Parrot  asserts  that  he  has  never  met  with  endo- 
carditis in  a  case  of  fatal  diphtheria.  He  believes  that  the  beading  else- 
where described,  which  is  almost  a  natural  condition  in  many  young- 
infants,  has  been  mistaken  for  the  result  of  inflammation.  Pericarditis,' 
however,  is  occasionally  present ;  and  in  a  few  instances  a  granular  degen- 
eration of  the  heart-walls  has  been  observed.  This  degeneration  is  con- 
sidered by  Ley  den,  of  Berlin,  to  be  of  an  inflammatory  character.  It  consists 
in  a  multiplication  of  the  intermuscular  nuclei  which  atrophy  and  form 
spots  of  degeneration.  At  the  same  time  the  muscular  fibres  undergo  fatty 
degeneration.  As  a  consequence  of  these  changes  the  heart- walls  become 
softer  in  consistence ;  extravasations  of  blood  take  place  into  them  ;  and 
"their  cavities  are  dilated. 

The  kidneys  may  be  enlarged  and  pale,  with  more  or  less  granular 
deposit  in  the  renal  cells.  The  cells  themselves  are  often  detached  so  as 
to  block  up  the  tubes.     They  are  mixed  with  hyaline  casts. 

Besides  the  above  changes,  there  may  be  extravasation  of  blood  into 
the  various  organs  and  beneath  the  mucous  and  serous  surfaces.  This 
occurs  in  the  malignant  form  of  other  varieties  of  acute  specific  disease. 

On  account  of  the  frequent  occurrence  of  paralysis  during  convalescence 


DIPHTHERIA — MORBID   ANATOMY — SYMPTOMS.  93 

from  diphtheria,  the  nervous  system  has  been  carefully  examined  for  signs  of 
degeneration.  Charcot  and  Vulpian  were  the  first  to  discover  indications 
of  pathological  change.  In  the  year  1862  these  observers  detected  granular 
degeneration  of  nerves  and  muscles  of  the  soft  palate.  In  the  motor  nerves 
of  this  part  the  tubules  were  emptied  of  their  medullary  substance,  and 
their  neurilemma  contained  many  granular  cells.  Oertel,  in  1871,  found 
many  extravasations  in  the  substance  of  the  brain,  spinal  cord,  and  spinal 
nerves  in  a  case  where  death  had  occurred  from  diphtheritic  paralysis  with 
general  atrophy  of  muscle.  Similar  extravasations  have  been  found  by 
Buhl.  In  addition,  this  observer  noticed  the  nerves  to  be  thickened  at 
their  roots,  and  their  sheaths  to  be  filled  with  hypertrophied  Ijanphoid 
cells  and  nuclei.  Dejerine,  in  five  cases  of  death  in  children  from  diph- 
theritic paralysis,  found  in  each  instance  changes  strictly  limited  to  the 
nerves  supplying  the  paralysed  parts.  These  changes  consisted  in  a  degen- 
eration of  the  anterior  roots  similar  to  that  which  takes  place  in  the  distal 
end  of  a  nerve  after  section.  He  attributes  the  degeneration  to  changes 
in  the  gray  matter  of  the  anterior  cornua. 

There  is  no  doubt  that  diphtheria  is  a  specific  contagious  disease,  and 
that  it  is,  at  least  finally,  a  constitutional  one  ;  but  opinions  differ  as  to 
whether  the  malady  is  constitutional  from  the  first.  The  more  commonly 
received  opinion  is,  perhaps,  that  the  affection  is  always  a  constitutional 
one,  and  that  the  throat  lesion  is  its  chief  local  expression,  analogous  to 
the  rash  of  specific  fevers.  Some  pathologists  are,  however,  inclined  to 
believe  that  the  lesion  of  the  mucous  membrane  is  at  first  a  purely  local 
ailment  resulting  directly  from  contact  with  the  poison,  just  as  the  pustule 
of  small-pox  may  be  excited  locally  by  the  process  of  inoculation.  Accord- 
ing to  this  view  the  constitutional  suffering  would  be  of  the  nature  of  sep- 
ticaemia, the  blood  being  directly  contaminated  by  absorption  of  a  specific 
virus  from  the  diseased  spot.  The  well-known  influence  of  a  catarrhal 
state  of  the  fauces  in  increasing  the  susceptibility  of  the  individual  to  the 
diptheritic  contagion  seems  to  lend  support  to  this  theory. 

Symptoms. — As  in  all  forms  of  zymotic  disease,  the  onset  of  the  illness 
is  preceded  by  a  period  of  incubation.  This  period  may  occupy  only  a 
few  hours  or  may  last  for  a  week  or  eight  days  before  the  symptoms  of  in- 
vasion are  noticed. 

Cases  of  diphtheria  may  be  divided,  according  to  the  gravity  of  the 
symptoms,  into  the  mild,  the  severe,  and  the  malignant  forms. 

In  the  mild  form  of  the  disease  the  child  is  a  little  feveiish,  often  com- 
plains of  headache,  and  is  unwilling  to  swallow  solid  food.  The  fever  is 
slight,  the  temperature  often  rising  to  between  101°  and  102°,  seldom 
higher.  (Thus,  in  the  case  of  a  little  girl,  aged  two  years  and  ten  months, 
temperature  :  second  day,  morning,  99.4°  ;  evening,  101.6°.  Third  day, 
morning,  99.4°  ;  evening,  101°.  After  this  date  the  temperature  was  normal 
both  morning  and  evening. )  In  all  cases  there  is  some  languor  and  loss 
of  spirits  with  a  certain  expression  of  distress  in  the  face.  Even  in  slight 
cases  a  little  change  is  noticed  in  the  quality  of  the  voice,  which  becomes 
nasal  or  throaty.  Vomiting  is  not  common  in  the  mild  form,  although  in 
the  severer  cases  it  may  be  a  frequent  and  distressing  sj'^mptom.  Some- 
times the  symptoms  are  even  less  marked.  The  child  may  take  his  food 
as  usual  without  any  complaint,  and  only  show  his  indisposition  by  a  cer- 
tain pallor  of  face  and  want  of  sprightliness  in  his  look. 

When  the  throat  is  examined,  the  fauces  are  found  to  be  red  and 
swollen,  but  more  on  one  side  than  on  the  other  ;  the  uvula  is  distinctly 
increased  in   size  ;  and  on  one  or  both  tonsils  a  gray  or  fawn-colored, 


04  DISEASE  lis-   CHILDEEIS". 

tough-looking  opaque  patcli  will  be  seen,  usually  occupying  the  anterior 
face.  The  patch  may  be  a  continuous  layer  of  some  consistence,  or  may 
be  composed  of  spots  of  false  membrane  scattered  over  the  surface.  These, 
however,  soon  unite  so  as  to  form  a  more  coherent  coating.  In  all  cases 
the  glands  at  the  angles  of  the  jaw  are  tender  and  enlarged  ;  but  this 
symptom  is  often  not  marked  until  the  end  of  the  second  or  the  beginning 
of  the  thu'd  day. 

In  the  mild  form  the  temperature  often  falls  after  three  or  four  days. 
The  general  symptoms  continue  trifling  ;  the  child  takes  food  with  appe- 
tite ;  and  unless  he  attempt  to  swaUow  solid  food,  deglutition  is  accom- 
panied by  httle  distress.  The  false  membrane  may  spread  a  little  along 
the  soft  palate^  but  usually  remains  limited  in  extent.  Very  quickly  it  be- 
gins to  separate  at  the  edges  and  then  becomes  detached.  In  rare  cases, 
after  spontaneous  separation  of  the  first  patch  of  membrane  a  second  ap- 
pears upon  the  mucous  surface.  I  have  known  this  to  happen  in  one  in- 
stance. The  sore  throat  may  be  accompanied  by  some  discharge  from  the 
nose.  Usually,  at  the  end  of  a  week  or  ten  days  the  child  is  convalescent 
from  the  throat  affection  ;  but  it  still  remains  to  be  seen  whether  he  will 
escape  after  ill-consequences. 

Li  the  severe  form  the  disease  may  be  severe  from  its  intensity  or  dan- 
gerotis  from  its  seat.  Thus,  it  may  spread  widely  over  the  pharynx  and  be 
accompanied  by  signs  of  serious  constitutional  suffering ;  or  may  attack 
the  larynx  and,  although  limited  in  extent,  produce  the  gravest  conse- 
quences from  interference  with  the  respiratory  process  (membranous 
croup). 

Severe  pharyngeal  diphtheria  may  begin  with  the  mild  general  symp- 
toms which  are  common  in  the  slighter  form  which  has  been  described  ; 
or  may  be  accompanied  by  much  more  serious  phenomena.  Thus,  the 
child  complains  of  difficulty  of  swallowing  and  of  racking  headache  ;  his 
face  is  pale  and  distressed  ;  fever  is  high  ;  vomiting  may  occur  on  any  at- 
tempt to  take  food ;  and  the  patient  may  even  be  convulsed.  The  false 
membrane  in  the  throat  is  thick  and  generally  coherent.  It  spreads  rapidly 
over  the  tonsils,  the  soft  palate,  and  the  back  of  the  pharjTix  ;  often  pene- 
trates into  the  nasal  fossae,  or  forms  patches  on  the  cheeks,  the  gums,  and 
the  lips.  The  odor  of  the  breath  is  soon  noticed  to  be  fetid  or  even  gan- 
grenous ;  and  a  thin  offensive  discharge  escapes  from  the  nostrils  and 
forms  crusts  at  the  openings  of  the  nares. 

The  submaxillary  glands  are  enlarged  and  tender  ;  and  there  is  much 
swelling  of  the  neck.  Sometimes  haemorrhages  occur  from  the  nose, 
throat,  and  gums.  The  face  is  pale  with  a  tendency  to  hvidity  ;  the  pulse 
is  rapid  and  feeble  ;  appetite  is  completely  lost ;  the  bowels  are  generally 
relaxed  with  thin  offensive  stools  ;  and  there  is  great  prostration.  Some- 
times in  these  cases  the  false  membrane  is  loose  in  consistence  and  may 
even  be  pultaceous.  It  may  assume  a  dirty  gray  or  brownish  hue,  and  is 
sometimes  almost  black  from  admixture  with  blood. 

When  the  end  is  favourable  this  form  lasts  for  ten  days  or  a  fortnight. 
After  a  time,  if  no  serious  complication  occurs,  the  false  membrane  sepa- 
rates and  is  not  renewed ;  the  swelling  subsides  ;  the  pulse  becomes 
stronger  ;  the  appetite  begins  to  return ;  and  the  child  enters  into  con- 
valescence, although  for  some  time  he  remains  anaemic  and  feeble.  Often, 
however,  the  patient  dies  at  the  end  of  the  week  either  from  exhaustion, 
from  extension  of  the  inflammation  to  the  larynx,  or  from  one  of  the  com- 
plications to  be  afterwards  described.  The  mind  is  usually  clear  through- 
out, although  in  the  worst  cases — those  in  which  the  disease  approaches 


DIPHTHEEIA — SYMPTOMS.  95 

most  nearly  to  the  malignant  type— death  may  be  preceded  by  delirious 
wanderings  or  stupor.  In  such  cases  a  real  septicaemia  may  occur,  the 
blood  being  poisoned  by  the  absorption  of  foul  putrescent  matters  in  con- 
tact with  the  tissues  of  the  pharynx.  The  child  often  shivers,  and  his 
temperature  rises  to  103°or  104°,  often  sinking  again  in  rapid  daily  varia- 
tions. The  pulse  is  small  and  feeble  ;  the  eyes  sunken  and  dull-looking ; 
the  complexion  of  a  dirty  yellow  tint.  There  is  often  epistaxis  ;  the  cer- 
vical glands  swell  to  a  large  size  ;  and  the  loose  areolar  tissue  of  the  neck 
is  infiltrated  Avith  serum.  The  prostration  is  extreme  ;  apathy  is  complete  ; 
delirium  comes  on  ;  and  the  child  quickly  dies. 

In  severe  diphtheria  the  amount  of  fever  varies.  Even  in  very  bad 
<;ases  it  need  not  be  high.  Sometimes  the  temperature  is  103°  or  104°  at 
ihe  beginning  of  the  illness,  and  sinks  to  the  normal  level  or  even  below 
it  when  the  more  serious  symptoms  declare  themselves.  Sometimes  after 
falling  it  may  again  become  elevated  and  reach  106°  or  higher  before 
death.     Some  inflammatory  complication  is  then  probably  present. 

Albuminuria  is  a  frequent  symptom.  It  occurs  in  about  two-thirds  of 
the  cases,  but  does  not  necessarily  imply  gravity  in  the  prognosis.  Its 
amount  is  usually  in  proportion  to  the  extent  of  surface  involved.  The 
albuminuria  appears  to  be  the  consequence  of  a  rapid  ehmination  through 
the  kidneys  of  poison  absorbed  from  the  affected  mucous  membrane.  In 
severe  cases  it  may  be  found  as  early  as  twenty-hours  from  the  beginning 
of  the  illness.  This  is,  however,  exceptional.  Usually  it  appears  on  the 
third  or  fourth  day,  but  it  may  be  sometimes  delayed  as  late  as  the  ninth 
or  tenth.  Sometimes  the  urine  is  smoky.  It  contains  an  excess  of  urea, 
and  hyaline  and  granular  casts  may  be  detected  in  the  deposit.  The  kid- 
neys are  in  a  state  of  mild  parenchymatous  nephritis,  but  this  passes  off  as 
convalescence  becomes  estabhshed,  and  rarely  leaves  ill  consequences  be- 
hind.    It  is  very  rare  for  uraemic  symptoms  or  dropsy  to  occur. 

When  the  disease  attacks  the  larynx  (laryngeal  diphtheria  ;  membranous 
croup)  the  child  is  at  once  in  serious  danger.  In  the  majority  of  cases  the 
laryngeal  disease  is  due  to  extension  of  inflammation  from  the  fauces. 
Less  commonly  the  inflammation  begins  in  the  trachea  and  spreads  thence 
ujDwards  and  downwards.  Cases  where  the  disease  develops  originally  in 
the  glottis  (the  so-called  true  membranous  croup)  are  very  rare.  Still 
rarer  are  the  cases  where  the  false  membrane  remains  limited  to  the  glot- 
tis. In  my  own  experience  I  cannot  call  to  mind  a  single  case  of  mem- 
branous laryngitis  in  which  some  evidence  of  false  membrane  in  other 
parts  was  not  to  be  obtained.  In  most  cases  there  was  also  exudation  in 
the  fauces.  In  a  few  the  membrane  had  spread  down  the  trachea  and  the 
fauces  were  free  ;  but  even  in  these  cases  patches  of  exudation  were  usu- 
ally found  on  examination  after  death  at  the  back  of  the  nares. 

The  extension  to  the  air-passages  often  takes  place  quite  suddenly  and 
unexpectedly.  The  preceding  symptoms  had  been  slight,  attracting  little 
attention,  when  suddenly  the  breathing  is  noticed  to  be  stridulous.  The 
symptoms  of  membranous  croup  then  develope  themselves  with  startling- 
rapidity.  Usually  the  sore  throat  and  signs  of  catarrh  continue  for  sev- 
eral days  before  any  more  alarming  symptoms  are  observed.  The  child  is 
not  thought  to  be  iU.  He  seldom  refuses  his  food ;  and  although  a 
little  languid  and  unusually  anxious  for  drink,  does  not  appear  to  be  dis- 
tressed. 

When  the  laryngeal  disease  begins  the  breath-sounds  lose  their  ordinary 
character  and  become  harsh  and  stridulous.  At  the  same  time  the  cough  is 
hard  and  harsh  and  the  voice  and  cry  are  hoarse.     The  change  in  the  char- 


96  DISEASE  i:n'  childeex. 

acter  of  the  breathing  may  be  the  earliest  of  the  new  symptoms,  or  may 
be  preceded  by  the  change  in  the  voice  and  cough. 

This  stage  of  the  disease  may  continue  for  several  days  ;  but  often  after 
a  few  hours  the  breathing  becomes  gxeatly  oppressed,  and  attacks  of  violent 
dyspnoea  thi'ow  the  patient  into  the  gi-eatest  distress.  In  these  attacks, 
however  violent  they  may  be,  there  is  no  orthopnoea,  for  the  breathing  is 
not  more  oppressed  when  the  head  is  low.  As  a  rule,  the  child  hes  back 
in  his  cot  or  in  his  mother's  arms.  His  face  is  hvid  ;  his  mouth  is  open  ; 
his  eyes  stare  wildly,  and  he  looks  dreadfully  anxious  and  frightened.  The 
dyspnoea  affects  both  respiratory  movements.  Each  inspiration  is  pro- 
longed, high-pitched,  and  metallic  ;  the  expirations  shorter  and  harsh  ;  the 
cough  hoarse  and  whispeiiag.  If  the  chest  is  uncovered  at  this  time  it 
will  be  noticed  that  at  each  iaspii-ation  the  lower  half  of  the  breast-bone 
bends  iawards  so  as  to  leave  a  cteep  pit  in  the  epigastrium.  At  the  same 
time  the  intercostal  spaces  deepen  and  the  supra-stemal  notch  is  depressed. 
The  attack  of  dyspnoea  lasts  from  a  few  minutes  to  a  quarter  of  an  hour  or 
longer.  WTien  it  subsides  the  child's  teiTor  disappears  ;  his  breathing  be- 
comes less  noisy  and  stridulous  ;  his  respii'atory  movements  less  laborious, 
and  he  passes  into  a  state  of  comparative  ease.  Still,  the  breathing  is- 
rapid  and  audible  ;  the  nares  work  violently  ;  some  li^ddity  remains  in  the 
face,  and  there  is  considerable  recession  of  the  soft  parts  of  the  chest  in 
inspu'ation.  On  examination  of  the  chest,  the  breath-sounds  are  accom- 
panied by  a  stridor  conducted  from  the  laiynx,  and  this  may  completely 
conceal  all  natui-al  vesicular  murmui-. 

The  attacks  of  dyspnoea  return  at  short  intervals,  and  are  easily  excited 
by  movement  or  by  anything  which  irritates  or  agitates  the  patient.  The 
cough  occui's  frequently  and  is  hoarse  and  whispering.  Sometimes  the 
jDatient  expectorates  patches  or  shi'eds  of  false  membrane  ;  but  unless  the 
trachea  be  opened  the  child  rarely  expels  enough  of  the  obstnicting  sub- 
stance to  produce  appreciable  relief  to  his  symptoms.  At  each  recuiTcnce 
of  the  dyspnoea  the  attack  is  more  severe  than  before,  so  that  gradually  the 
child  passes  into  a  seiai-asphyxiated  state.  He  hes  back  with  j)ui'ple  lips 
and  hvid  face  ;  his  pulse  is  feeble,  frequent,  and  very  irregular  ;  his  breath- 
ing rapid  and  shallow,  although  his  nai-es  stiU  work  ;  his  forehead  clammy, 
and  his  extremities  cold.  He  often  moves  his  arms  restlessly,  and  his 
heart's  action  may  become  very  intermittent,  a  curious  pause  taking  place 
between  every  two  or  three  pulsations.  On  examination  of  the  chest  there 
is  usually  good  resonance,  except  perhaps  at  the  extreme  base.  The  breath- 
sounds  are  obscured  by  conducted  stridor  and  may  be  accompanied  by  dry 
rhonchus.  If  no  operative  procedure  be  attempted  the  drowsiness  deepens 
into  stuj)or,  and  the  child  sinks  quietly  or  dies  in  a  last  struggle  for 
breath. 

If  at  this  stage  the  trachea  be  opened,  the  immediate  effect  of  the 
operation  is  most  striking.  In  a  favoui-able  case,  where  the  trachea  below 
the  opening  is  not  obstructed,  the  child  is  at  once  reheved  fi'om  almost  all 
his  distress.  Aii'  again  penetrates  deeply  into  the  lungs ;  the  hvidity  dis- 
appears ;  the  restlessness  subsides ;  the  breathing  becomes  natural ;  the 
nares  cease  to  act,  and  the  look  of  terror  and  suffeiing  passes  off'  and  may 
even  be  succeeded  by  a  smile. 

When  the  disease  thus  attacks  the  larynx  the  dui'ation  is  usuallv  very 
short,  From  the  thne  when  the  first  signs  of  stiidulous  breathing  are 
noticed  to  the  end  only  a  few  houi*s  may  elapse.  In  other  cases  the  child 
may  live  two  or  three  days  ;  but  this  longer  dui-ation  is  due  to  slower 
progress  in  the  earlier  part  of  the  ilhiess.     When  serious  dyspnoea  super- 


DIPHTHERIA — COMPLICATIOISrS.  97 

venes  the  child,  if  not  reheved  by  operation,  seldom  survives  the  next 
twenty-four  hours.  Sometimes,  however,  if  the  false  membrane  is  very 
limited  in  extent,  recovery  may  take  jDlace.  In  these  cases  the  symptoms 
are  seldom  very  severe,  and  in  pai-ticular  the  attacks  of  dyspnoea,  if  pres- 
ent at  all,  are  mild  and  infrequent.  The  favourable  change  is  marked  by  a 
less  laboured  character  of  breathing,  a  brighter  look  in  the  face,  increased 
looseness  and  more  natural  quality  of  the  cough,  and  a  return  of  tran- 
quillity to  the  manner.  Still,  there  is  little  doubt  that  many  cases  of 
supposed  recovery  from  membranous  croup  are  really  cases  of  stridulous 
laryngitis,  which  is  a  much  milder  complaint  and  rarely  ends  fatally. 

In  the  malignant  form  of  the  disease  the  constitutional  symptoms  are 
very  severe,  and  may  be  quite  out  of  pro]Dortion  to  the  amount  of  local 
lesion.  Vomiting  is  usually  fi-equent.  There  is  often  diarrhoea.  The 
child  is  pale  and  haggard-looking,  and  seems  stupid  and  di'owsy.  His  skin 
is  spotted  with  petechise.  His  pulse  is  rapid,  small,  and  feeble.  His  feet 
and  hands  are  cool  and  clammy,  and  even  the  internal  temperature  of  the 
body  seldom  reaches  a  high  elevation.  Sometimes,  indeed,  it  is  normal  or 
even  subnormal.  Thus  a  httle  boy,  aged  two  years  and  a  half,  was  ad- 
mitted into  the  East  London  Children's  Hospital  with  wash-leather-like 
exudation  on  the  fauces,  great  swelling  of  the  cervical  glands,  and  marked 
prostration.  In  this  boy  the  temperature  never  rose  above  98.2°,  and  a  few 
hours  before  death  was  only  97°  in  the  rectum.  The  child  died  two  days 
after  admission  in  a  convulsive  fit. 

The  false  membrane  is  generally  of  a  dirty-brown  coloiu'.  Extension  of 
the  inflammation  takes  place  rapidly  into  the  nose  ;  epistaxis  often  occurs, 
or  there  is  a  flow  of  thin  blood-stained  fluid  from  the  nostrils.  Sometimes 
the  lachrymal  ducts  become  obstructed  ;  the  eyes  then  look  watery,  and 
false  membrane  may  even  ajDpear  on  the  conjunctivae.  The  mucous  mem- 
brane of  the  fauces  may  become  ulcerated  or  gangrenous,  and  the  smell 
from  the  mouth  is  very  offensive.  Hsemorrhages  may  occur  fi'om  the  gums 
and  throat.  The  urine  is  often  smoky  and  almost  always  albuminous, 
Dehrium  comes  on  followed  by  stupor,  and  the  child  dies  exhausted. 

Secondary  Diphtheria. — Sometimes  diphtheria  occurs  secondaiily  to  some 
acute  disease.  Thus  it  may  arise  as  a  complication  of  typhoid  fever, 
pyaemia,  erysipelas,  measles,  scarlatina,  whooping-cough,  or  other  form  of 
acute  illness.  In  these  cases  the  amount  of  false  membrane  is  usually 
limited  in  extent,  but  the  inflammatory  process  is  apt  to  run  on  into  ul- 
ceration or  even  gangrene.  The  ulcers  are  rounded  or  sinuous,  and  may 
penetrate  deeply  into  the  tissues.  Gangi'ene  is  not  common.  It  usually 
occurs  in  the  tonsils  and  pillars  of  the  fauces.  These  parts  become  gray 
and  exhale  a  most  offensive  odoui'.  The  sloughs  separate  after  a  time  and 
leave  grayish,  unhealthy -looking  pits  which  in  favourable  cases  may  heal, 
with  considerable  contraction  of  tissu.e  in  the  affected  parts. 

Complications. — The  ordinary  coui-se  of  diphtheria  may  be  interfered 
"with  by  various  comj)lications  which  delay  recovery  or  unfavourably  in- 
fluence the  issue  of  the  illness.  The  occurrence  of  albuminuria  cannot 
be  looked  upon  as  a  comphcation.  This  symptom  is  found  in  mild  as 
well  as  in  severe  cases,  and  is  far  more  often  present  than  absent.  It  ap- 
pears to  be  the  consequence  of  elimination  of  the  poison  by  the  kidneys, 
and  has  probably  Httle  influence  on  the  prognosis.  The  complications 
which  mil  be  considered  consist  of  the  formation  of  false  membrane  in 
unusual  situations  ;  the  occurrence  of  inflammation  of  special  oi-gans,  such 
as  the  lungs,  the  heart,  and  the  pericardium  ;  the  formation  of  a  thi'ombus 
in  the  heart  or  large  vessels  ;  and  the  appearance  of  paralysis. 


98  DISEASE   IjN'   CHILDEEN.       » 

Nasal  diplitlieria  has  been  already  referred  to  as  constituting  a  symp- 
tom of  the  malignant  type  of  the  disease.  A  diphtheritic  coryza  is,  how- 
ever, sometimes  seen  as  a  complication  of  milder  attacks.  In  these  cases 
a  thin  discharge  flows  from  the  nostril,  usually  at  first  on  one  side  only. 
It  produces  some  excoriation  of  the  margin  of  the  nasal  opening  as  well  as 
of  the  upper  lip,  for  these  parts  are  often  red  and  raw-looking.  No  doubt 
the  presence  of  false  membrane  in  the  nasal  passages  is  a  sign  of  the  ut- 
most gravity  ;  but  I  have  known  coryza  with  excoriation  of  the  nostril  to 
occur  in  cases  of  a  comparatively  mild  nature  without  producing  an  unfa- 
voui'able  influence  upon  the  course  of  the  illness. 

Sometimes  in  epidemics  of  diphtheria  more  uniisual  manifestations  of 
the  disease  are  met  with.  The  false  membrane  may  form  upon  the  con- 
junctivEe,  the  external  auditory  meatus,  the  outlets  of  the  vagina  and  rec- 
tum, upon  the  glans  penis,  and  upon  any  wounds  or  abraided  surfaces 
joresent  on  the  skin.  Often  after  tracheotomy  the  edges  of  the  wound 
quickly  become  covered  by  the  diphtheritic  exudation.  These  exceptional 
seats  of  the  false  membrane  may  be  the  only  local  signs  of  the  disease 
to  be  discovered,  or  may  be  accompanied  by  the  usual  affection  of 
the  throat.  "\Vhen  a  wound  or  abraided  surface  becomes  attacked  by  the 
diphtheritic  process,  its  borders  become  purple -red  and  swollen,  and  the 
surface  pours  out  a  profuse,  watery,  fetid  discharge.  Soon  a  pellicle 
forms  on  the  sore,  and  from  this  point  the  disease  may  spread  over  the 
skin.  Thus  the  discharg-e  irritates  the  neighbouring  cutaneous  surface  ; 
little  vesicles  form,  break,  and  become  themselves  converted  into  diphthe- 
ritic sores  covered  by  the  characteristic  false  membrane.  In  this  way,  ac- 
cording to  Trousseau,  the  diphtheritic  jorocess  may  spread  over  a  large  ex- 
tent of  surface  ;  and  the  layers  of  membrane,  constantly  moistened  by  the 
discharge,  undergo  rapid  decomposition,  and  give  out  a  most  offensive 
gangrenous  stench.  The  general  symptoms  in  such  cases  are  very  severe, 
and  the  patient  usually  sinks  rapidly  from  exhaustion. 

Inflammatory  comiDlications  sometimes  arise  in  the  course  of  diphthe- 
ria. After  the  operation  of  tracheotomy  for  membranous  croup,  it  is  un- 
fortunately far  from  uncommon  to  find  the  temperatru-e  rise  to  102°  or 
103°,  and  to  discover,  on  examination  of  the  chest,  all  the  signs  of  acute 
consolidation  of  the  lung.  Sometimes,  however,  the  pulmonary  lesion  is 
an  early  comjDlication.  In  any  case  it  greatly  lessens  the  child's  chances 
of  recovery. 

Inflammation  of  the  pericardium  and  endocardium  are  occasional  com- 
plications of  the  illness.  Pericarditis  occurring  alone  will  probably  be 
overlooked  without  a  careful  examination  of  the  precordial  region.  Endo- 
carditis also  may  give  rise  to  but  few  symptoms,  and  is  often  only  dis- 
covered on  examination  of  the  body  after  death.  We  must,  however,  be 
on  our  guard,  and  avoid  attributing  to  endocarditis  the  heematomatous 
beading  of  the  mitral  valve  described  by  Parrot.     (See  page  546.) 

"When  a  thrombus  forms  in  the  heart,  death  may  occiir  either  suddenly 
at  the  moment  of  formation  of  the  coagulum,  or  gradually  after  an  interval 
of  much  anxiety  and  suffering.  Usually  the  symptoms  appear  quite  sud- 
denly, and  at  a  time  when  the  child  seems  to  be  going  on  favourably  to  con- 
valescence, or  even  after  recovery  is  far  advanced.  If  the  formation  of  the 
clot  does  not  bring  the  case  to  a  sudden  termination,  marked  dyspnoea  is 
one  of  the  earliest  signs  of  the  accident. 

Dyspnoea  arising  from  want  of  blood  in  the  puhnonary  circulation  is 
shown,  as  Dr.  Kichardson  has  pointed  out,  by  symptoms  very  different  in 
character  from  those  due  to  an  obstructed  larynx.     In  the  first  case,  al- 


DIPHTHERIA — PARALYSIS.  99 

though  the  breathing  is  laboured,  the  lungs  are  full  of  air  and  may  even 
be  distended  with  it  sufficiently  to  produce  in  the  younger  subjects  a  pecu- 
liar prominence  in  the  anterior  part  of  the  chest.  There  are  no  signs  of 
imperfect  aeration  of  blood,  but  all  the  sjTnptoms  indicate  obstruction  to  the 
circulatory  current.  Thus  the  lips  and  cheeks  are  blue  ;  the  jugular  veins 
distended  ;  the  heart-impulse  quick,  feeble,  and  UTegular.  The  body  is 
cold  and  pale  ;  it  may  be  marbled,  especially  at  the  extremities  ;  and  there 
is  intense  anxiety  and  constant  movement.  When  death  occurs,  the  heart 
ceases  to  act  before  the  respiratory  movements  have  come  to  an  end. 

On  the  other  hand,  when  apnoea  occurs  from  laryngeal  obstruction  the 
symptoms  all  point  to  imperfect  aeration  of  blood.  The  surface  of  the  body 
is  dusky  instead  of  pale  ;  the  heart-sounds  are  clear ;  the  cardiac  impulse 
is  feeble  but  rarely  tumultuous  ;  the  lungs  are  congested  but  not  emphyse- 
matous ;  there  is  great  recession  of  the  epigastrium  and  soft  parts  of  the 
chest  at  each  inspiration  ;  the  muscles  are  convulsed ;  and  the  breathing 
stops  before  the  movements  of  the  heart  cease. 

Sudden  death  is  due  in  most  cases,  probably,  to  the  rapid  formation  of 
a  clot  in  the  right  side  of  the  heart.  It  may  be  also  the  consequence 
of  paralysis  of  the  cardiac  branches  of  the  par  vagum ;  but  in  cases  where 
the  sudden  end  has  been  attributed  to  this  cause,  a  gTanular  degeneration 
of  the  cardiac  muscular  fibres  with  softening  of  the  walls  and  dilatation  of 
the  cavities  has  been  discovered  on  careful  examination.  Leyden  suggests 
that  the  cardiac  failure  is  the  result  of  these  changes.  According  to  this 
observer,  dangerous  weakness  of  the  heart  from  this  cause  is  indicated  by 
gallop-rhythm  of  the  heart-sounds  vdth  weakness  of  the  impulse  and  irreg- 
ular tremulous  contractions.  Vomiting,  due  to  a  reflection  of  the  disturb- 
ance to  other  parts  of  the  pneumogastric  nerve,  indicates  that  the  danger  is 
pressing.  Other  observers  have  noted  precordial  distress,  extreme  dysp- 
noea, smallness  and  irregularity  of  the  pulse,  and  attacks  of  palpitation 
alternating  with  slowness  of  the  pulsations.  H.  Weber  has  found  the  pulse 
fall  to  twenty-eight  or  even  sixteen  beats  in  the  minute. 

In  a  certain  proportion  of  cases  of  diphtheria  convalescence  is  inter- 
rupted by  the  appearance  of  paralytic  lesions.  The  frequency  with  which 
this  comiDhcation  is  found  to  occur  has  been  variously  estimated.  Probably 
it  depends  in  some  measure  upon  the  character  of  the  epidemic.  The  de- 
gree, too,  to  which  the  nervous  system  is  affected  is  subject  to  great 
variety.  In  some  cases  the  lesion  is  so  trifling  as  scarcely  to  attract  atten- 
tion. In  others  it  amounts  to  weU-defined  and  general  loss  of  power. 
Taking  mild  and  severe  forms  together,  the  proportion  of  patients  who 
suffer  from  the  complication  is  probably  one  in  every  ten  or  twelve  cases. 

Diphtheritic  paralysis  is  not  limited  to  cases  in  which  the  throat  affec- 
tion has  been  severe.  The  sHghter  forms  of  the  distemper  are  as  hable  as 
the  more  serious  forms  to  be  followed  by  the  nerve-lesion.  Nor  is  its  oc- 
currence determined  by  the  seat  of  the  diphtheritic  manifestation  or  the 
presence  or  absence  of  albuminuria.  It  may  follow  in  cases  where  the  false 
membrane  has  been  hmited  to  the  skin,  and  in  cases  where  albuminuria 
has  not  been  observed.  The  period  at  which  the  paralysis  appears  is  also 
subject  to  variety.  From  an  analysis  of  sixteen  cases  Dr.  Abercrombie 
found  that  the  paralytic  complication  might  appear  from  two  to  five  weeks 
from  the  beginning  of  the  illness.  Sanne  has  noticed  it  as  early  as  the 
second  or  third  day  of  the  disease,  but  states  that  it  generally  comes  on 
from  one  to  two  weeks  after  the  disappearance  of  the  false  membrane. 
According  to  this  obseiwer,  when  the  paralytic  symptoms  appear  early  they 
usually  develop  gradually  and  spread  slowly  from  one  part  to  another. 


100  DISEASE  IlSr   CHILDEEIS". 

When  the  onset  is  retarded,  the  development  of  the  paralytic  phenomenar 
is  much  more  rapid  and  regular. 

The  motor  lesion  may  be  preceded  by  increase  of  languor  and  irritabil- 
ity of  temper.  Dr.  Hermann  Weber  has  noticed  in  many  cases  a  marked 
diminution  in  the  rapidity  of  the  pulse.  The  paralysis  is  symmetrical  as  a 
rule.  Usually  it  begins  either  by  loss  of  power  in  the  soft  palate  and  phar- 
ynx or,  by  what  is  equally  common,  paralysis  of  accommodation  of  the 
eye.  It  is  noticed  that  when  the  child  attempts  to  swaUow  he  coughs  vio- 
lently and  fluids  return  through  the  nose.  His  voice  has  a  nasal  quality 
and  he  snores  in  his  sleep.  If  the  patient  is  old  enough  we  can  ascertain 
by  inspection  that  he  has  no  power  of  elevating  the  uvula,  and  perhaps, 
also,  that  there  is  more  or  less  ansesthesia  of  the  fauces.  If  the  ocular 
muscles  are  affected  the  child  complains  that  he  sees  double.  Reading  is 
difficult  or  impossible,  and  sometimes  there  is  an  evident  squint.  In  rai'e 
cases  there  is  temporary  blindness. 

When  the  pharjmx  is  fii'st  affected  the  paralysis  may  remain  Hmited  to 
this  part.  If  it  be  complete,  the  power  of  swallowing  is  lost  and  food  can 
no  longer  be  propelled  down  the  gullet.  The  food  taken  is  found  to  col- 
lect in  a  pouch  formed  by  yielding  of  the  waUs  of  the  oesophagus.  In  such 
cases  nourishment  has  to  be  conveyed  to  the  stomach  by  mechanical  means. 
The  use  of  the  stomach-tube  is  of  the  greatest  service  in  these  cases,  both 
as  a  method  of  maintaining  nutrition  and  also  as  a  means  of  preventing 
the  entrance  of  food  into  the  glottis.  From  the  pharynx  the  paralysis  may 
spread  to  other  parts.  The  tongue  and  Hps  may  become  affected  so  that 
the  child  dribbles  and  speech  is  greatly  interfered  with.  Loss  of  power 
may  also  be  noticed  in  the  limbs,  the  neck,  and  the  back.  Of  the  Hmbs, 
the  legs  are  affected  more  commonly  than  the  arms.  The  paralysis  almost 
invariably  takes  the  form  of  paraplegia,  for  even  if  the  weakness  is  more 
marked  on  one  side,  it  will  be  usually  found  on  examination  that  the  side 
which  appears  to  be  sound  has  not  entii-ely  escaped.  The  motor  paralysis 
may  be  accompanied  by  some  disturbance  of  sensation.  In  rare  cases  con- 
trol over  the  sphincters  is  lost.  Paralysis  of  the  respu-atory  muscles  some- 
times occurs.  There  is  then  dyspnoea  :  mucus  collects  in  the  lungs,  for 
there  is  no  power  to  cough  it  up  ;  and  the  child  usually  dies  suffocated. 
If  the  diaphragm  is  paralysed  the  child  has  attacks  of  dyspnoea,  coming  on 
at  the  shghtest  excitement  or  when  an  attempt  is  made  to  cough.  Death 
may  ensue  in  such  an  attack.  The  most  moderate  catarrh  in  such  a  con- 
dition adds  an  additional  element  of  danger  to  the  case. 

Besides  these  forms  of  motor  lesion,  sudden  death,  attributed  to  paraly- 
sis of  the  heart,  has  been  akeady  referred  to  (see  page  99). 

Diphtheritic  paralysis  is  fatal  only  in  exceptional  cases.  When  death 
occurs,  it  is  usually  the  consequence  of  cardiac  thrombosis  or  sjmcope  ; 
less  commonly  it  is  due  to  impaired  nutrition  through  difficulty  of  swal- 
lowing, or  to  nervous  exhaustion.  Recovery  is  the  rule,  and  the  rapidity 
with  which  this  takes  place  is  very  variable.  The  course  is  much  shorter 
in  cases  where  the  x;)aralysis  is  limited  to  the  palate.  This  usually  passes 
off  in  a  fortnight  or  three  weeks.  When  the  loss  of  power  becomes  gen- 
eral, a  cure  is  effected  with  much  greater  difficulty  ;  but  even  in  these  cases 
it  seldom  lasts  longer  than  three,  or  at  the  most  four  months.  Sometimes 
the  limbs  recover  their  power  very  rapidly  while  the  pharjTix  remains  ob- 
stinately paralyzed  for  a  considerable  longer  period. 

Diagnosis. — When  diphtheria  gives  rise  to  well-marked  symptoms,  its 
detection  is  easy.  The  tough-lookiug  gray  or  fawn-coloured  membrane  in 
the  throat,  the  redness  and  swelling  of  the  fauces,    and  the  enlarged  cer- 


DIPHTIIEEIA — DIAGJSrOSIS,  101 

rical  glands  are  sufficiently  characteristic.  In  tonsillitis  the  uvula  is  not 
swollen,  and  the  whitish  exudation  occupying  the  mouths  of  the  crypts, 
and  sometimes  spotting  the  surface  of  the  tonsils,  is  very  different  in  ap- 
pearance from  the  consistent  false  membrane  of  diphtheria.  It  never  forms 
a  coherent  layer,  and  never  invades  the  nares  or  the  larynx.  Moreover, 
in  quinsy,  although  the  swollen  tonsils  can  be  felt  externally,  the  cervical 
glands  are  seldom  appreciably  enlarged.  If,  in  diphtheria,  the  exudation 
is  soft  and  pultaceous,  instead  of  being  coherent  and  tough,  there  is  still 
enlargement  of  the  superficial  cervical  glands,  and  the  general  symptoms 
indicate  profound  depression.  Any  huskiness  or  weakness  of  the  voice 
implies  extension  of  the  inflammation  to  the  larynx,  and  points  unmistak- 
ably to  diphtheria.  The  difficult  cases  to  detect  are  those  in  which  the 
throat  affection  is  imperfectly  developed,  or  is  slow  to  appear.  At  first, 
nothing  may  be  noticed  but  redness  and  swelling  of  the  fauces,  with  some 
discomfort  in  swallowing.  In  such  cases  until  the  false  membrane  ap- 
pears, we  cannot  say  that  we  have  not  to  deal  with  an  ordinary  inflamma- 
tory sore  throat ;  for  although  the  weakness  and  pallor  of  the  patient  are 
usually  out  of  proportion  to  the  apparent  mildness  of  the  local  affection, 
no  positive  inference  can  be  drawn  from  this  discrepancy,  as  some  chil- 
dren are  more  depressed  than  others  by  a  trifling  ailment.  If  such  a  con- 
dition be  met  with  at  a  time  when  diphtheria  is  known  to  be  prevalent, 
we  should  regard  the  symptoms  with  much  apprehension.  Indeed,  in  any 
case  of  sore  throat,  if  enlargement  of  the  glands  of  the  neck  can  be  dis- 
covered, we  should  withhold  a  positive  assurance  that  the  complaint  is  one 
of  little  consequence.  Sometimes  the  appearance  of  albumen  in  the  urine 
comes  opportunely  to  clear  up  a  doubtful  case.  Sometimes  after  the  ter- 
mination of  an  ill-defined  angina,  the  occurrence  of  paralysis  throws  a  new 
light  upon  the  past  indisposition. 

Laryngeal  diphtheria,  or  membranous  croup,  may  be  confounded  with 
stridulous  laryngitis,  with  abscess  of  or  about  the  larynx,  or  with  retro- 
pharyngeal suppuration.  The  distinctive  points  between  these  diseases 
will  be  referred  to  in  the  chapters  treating  of  these  affections.  It  is  pos- 
sible that  a  foreign  body  in  the  air-passages  may  be  mistaken  for  croup  ; 
but  the  attack  of  dyspnoea  produced  by  this  means  comes  on  quite  sud- 
denly and  foUows  at  once  upon  an  attempt  to  swallow.  There  is  spas- 
modic cough  but  no  hoarseness  ;  and  the  first  paroxysm  of  suffocation  and 
cough  is  usually  succeeded  by  a  period  of  quiet  in  which,  for  the  time,  the 
breathing  is  fairly  easy  and  the  child  seems  to  be  well. 

It  is  very  important  to  be  able  to  discriminate  between  cases  in  which 
tracheotomy  may  be  expected  to  succeed  and  those  in  which  no  perma- 
nent good  can  be  anticipated  from  the  operation.  Dr.  George  Buchanan, 
of  Glasgow,  has  pointed  out  that  in  cases  where  the  air-passages  below  the 
point  of  obstruction  are  free,  and  the  lungs  are  in  a  normal  condition, 
there  is  great  recession  of  all  the  soft  parts  of  the  chest.  At  each  insj)ira- 
tion  the  intercostal  spaces  fall  deeply  in,  and  the  epigastrium  forms  a  deep 
hollow.  If,  on  the  contrary,  the  smaller  bronchial  tubes  are  fuU  of  mucus 
or  diphtheritic  exudation,  the  movements  of  the  chest-wall  are  impeded, 
and  the  chest  is  puffed  out  so  as  to  resemble  the  distended  thorax  of 
chronic  emphysema. 

If  the  patient  be  seen  for  the  first  time  when  the  paralytic  symptoms 
have  declared  themselves,  the  history  of  the  attack  will  declare  the  nature 
of  the  disease.  Even  if,  as  sometimes  happens,  the  throat  affection  has 
been  too  slight  to  constitute  a  regular  illness,  we  shall  find,  probably,  that 
other  members  of  the  household  have  suffered  from  diphtheria,  and  that, 


102  DISEASE  IN   CHILDEEN. 

in  the  child  himself,  any  signs  of  general  nerve-lesion  have  been  preceded 
by  a  nasal  tone  of  voice,  some  trouble  in  swallowing,  and  the  occasional 
retui'n  of  fluids  through  the  nose. 

According  to  M.  Landrouzy,  if  a  child  who  is  convalescent  from  diph- 
theria begins  to  suffer  from  attacks  of  dyspnoea  excited  by  an  attempt  to 
cough,  or  by  any  small  vexation,  we  should  suspect  paralysis  of  the  dia- 
phragm in  the  absence  of  any  more  evident  explanation  of  the  distressing- 
phenomenon. 

Prognosis. — Even  in  the  mildest  attack  of  diphtheria  we  must  be 
guarded  in  the  expression  of  our  opinion  as  to  the  probable  issue  of  the 
iUness.  Indeed,  it  is  wiser  to  express  no  opinion  upon  the  matter,  but 
to  confine  ourselves  to  reporting  the  daily  progress  of  the  case,  and  speak- 
ing cheerfully  so  long  as  no  symptoms  arise  indicative  of  danger.  We  can 
never  feel  certain  that  the  inflammation  may  not  spread  to  the  larjTix,  or 
that  other  ill  consequences  may  not  ensue,  however  favourably  the  disease 
may  aj^pear  to  be  going  on.  Caution  in  prognosis  is  esj)ecially  necessary 
if  the  epidemic  is  a  severe  one,  for  outbreaks  of  the  distemper  vary 
greatly  in  the  severity  of  type  of  the  illness,  and  in  some  the  mortality  is 
much  greater  than  it  is  in  others.  The  age  of  the  patient  is  also  an  impor- 
tant item  to  take  into  consideration,  for  a  young  child  has  fewer  chances 
of  recovery  than  an  older  one. 

Diflerent  dangers  are  to  be  apprehended  at  different  periods  of  the  dis- 
ease. During  the  first  week  we  dread  lest  the  inflammation  should 
spread  to  the  larynx,  or  lest  the  child  should  die  from  septiceemia.  We 
therefore  notice  carefuUy  the  character  of  the  breathing  and  the  quahty  of 
the  voice.  If  the  breathing  become  shrill  and  the  movements  laboured,  or 
the  voice  get  weak  or  husky,  we  can  have  no  doubt  that  the  larynx  is  be- 
coming involved.  So,  also,  in  cases  where  the  false  membrane  is  thick, 
pulpy,  and  putrescent  the  occurrence  of  shivering  or  a  sudden  rise  in  the 
temperature,  with  a  dull  yellow  tint  of  the  face  and  a  rapid  feeble  pulse, 
makes  us  fear  that  the  blood  is  becoming  poisoned  by  absorjDtion  from  the 
affected  mucous  membrane.  Dr.  Jacoby  has  pointed  out  that  in  nasal 
diphtheria  septicaemia  is  especially  liable  to  occur.  In  this  form  of  the 
disease,  therefore,  the  regular  use  of  disinfecting  injections  is  imperatively 
called  for. 

After  the  first  six  or  seven  days  the  child  is  in  danger  of  death  from 
syncope,  from  clotting  of  blood  in  the  heart,  and  from  inflammatory  com- 
plications. At  this  time  we  carefully  watch  the  pulse.  If  this  fall  notably 
in  frequency  and  strength,  especially  if  at  the  same  time  vomiting  occur 
and  be  often  repeated,  the  danger  is  imminent.  At  this  period  of  the  dis- 
ease haemorrhages  sometimes  come  on  as  a  result  of  profound  blood  con- 
tamination and  are  very  exhausting.  Other  signs  of  bad  augury  are':  a 
very  feeble  frequent  pulse,  cardiac  dyspnoea  (see  page  98),  general  swell- 
ing of  the  neck,  great  prostration,  and  delirious  wanderings.  Albumi- 
nuria, unless  excessive,  is  not  necessarily  a  grave  symptom. 

When  the  diphtheritic  exudation  invades  the  trachea  the  danger  is  very 
serious  ;  but  if  the  operation  of  tracheotomy  be  performed  in  time,  and  a 
marked  retraction  of  the  chest-wall  indicates  that  the  smaller  tubes  are 
free  below  the  point  of  obstruction,  and  that  air,  if  admitted,  will  be  able  to 
penetrate  to  the  alveoli,  recovery  is  far  fi'om  impossible.  After  the  oper- 
ation, success  depends  chiefly  upon  the  child's  capability  of  taking  and  di- 
gesting his  food,  and  upon  the  lungs  remaining  free  from  pneumonia.  If 
there  is  difficulty  in  administering  nourishment,  the  child  can  be  still  fed 
through  the  stomach-tube  ;  but  loss  of  appetite  usually  imphes  feeble  di- 


DIPHTHEEIA — PROGNOSIS — TREATMENT.  103 

gestive  power,  and  the  prospect  is  not  favourable.  If  pneumonia  occur,  the 
prognosis  is  gloomy. 

After  the  end  of  the  second  or  third  week  nervous  symiDtoms  may  be 
expected.  In  these  the  prognosis  is  favourable.  It  only  becomes  serious 
when  the  lesion  is  widely  diffused,  when  all  the  muscles  of  deglutition  are 
affected  so  that  swallowing  becomes  impossible,  or  when  the  diaphragm 
and  respiratory  muscles  are  attacked.  No  child,  however,  should  be  al- 
lowed to  die  of  starvation,  for  nourishment  can  always  be  administered  at 
regular  intervals  through  the  stomach-tube  passed  through  the  nose. 

Treatment. — Diphtheria  is  an  infectious  disease,  and  the  ordinary  pre- 
cautions must  therefore  be  taken  against  its  spread.  The  sick  room  should 
be  divested  of  carpets,  rugs,  curtains,  and  superfluous  furniture  ;  and 
proper  measures  should  be  taken  to  disinfect  all  discharges  from  the  patient 
before  removal. 

The  child  must  be  kept  quiet  in  bed.  It  is  well  to  place  him  in  a  tent 
bedstead  and  to  envelop  him  in  an  atmosphere  of  steam  impregnated  with 
thymol,  creasote,  or  other  disinfectant.  Tiiis  may  be  most  conveniently  done 
by  the  use  of  the  "croup  kettle  "  designed  by  IMr.  E.  W.  Parker,  on  the 
principle  of  Dr.  Lee's  "  steam  draught  inhaler."  Creasote  or  carbolic  acid 
may  be  added  to  the  water  in  the  kettle  in  the  proportion  of  twenty  drops 
to  the  pint,  or  a  saturated  solution  of  thymol  can  be  made  use  of.  So 
many  technical  matters  have  to  be  attended  to  in  the  treatment  of  these 
cases  that  whatever  be  the  age  of  the  child  the  assistance  of  a  skilled  nurse 
is  indispensable.  Amateur  nursing,  seldom  if  ever  satisfactory,  is  here  a 
serious  disadvantage  to  the  patient,  and  introduces  into  the  case  an  addi- 
tional element  of  danger. 

The  treatment  of  the  disease  comprises  general  and  local  measures,  and 
these  are  of  about  equal  importance. 

The  general  treatment  consists  in  employing  every  means  to  support 
the  strength  of  the  child,  so  as  to  enable  him  to  struggle  successfully 
against  the  exhausting  influence  of  the  disorder.  The  patient  should  be 
supplied  with  food  of  a  nourishing  and  digestible  kind.  Strong  beef  es- 
sence, yolk  of  egg,  milk  thickened  with  Chapman's  entire  wheat  flour 
baked  in  an  oven,  pounded  underdone  meat  made  fluid  with  strong  meat 
juice  or  meat  essence,  all  these  are  very  useful.  Alcohol  must  not  be  for- 
gotten, and  will  often  have  to  be  given  in  full  doses.  Old  brandy  or 
whiskey,  with  or  without  yolk  of  egg,  should  be  given  at  the  first  sign  of 
feebleness  of  the  pulse.  A  child  five  years  of  age  will  take  with  benefit 
thirty  drops  of  good  brandy  every  two  hours.  In  infants  white  wine  whey 
given  freely  is  very  useful.  In  giving  stimulants  we  must  be  guided  by 
the  state  of  the  pulse,  or  in  infants  by  the  condition  of  the  fontanelle.  As 
long  as  the  pulse  is  firm  or  the  fontanelle  little  depressed,  alcohol  is  not  re- 
quired, when  the  pulse  gets  soft  and  comj)ressible,  or  the  fontanelle  sinks, 
stimulants  must  be  given  without  delay.  It  some  cases  they  wiU  be  re- 
quired from  the  first. 

In  the  selection  of  medicines  preference  should  be  given  to  such  as  do 
not  cause  depression.  In  diphtheria  there  is  a  tendency  to  failure  of  the 
heart's  action  ;  and  this  tendency  is  likely  to  be  favoured  by  the  use  of  de- 
pressing remedies,  such  as  the  salicylate  of  soda,  which  has  been  sometimes 
recommended.  A  simple  febrifuge  may  be  given  while  the  temperature  is 
high  and  the  skin  dry  ;  but  directly  the  strength  shows  signs  of  failing,  iron 
and  quinine  should  be  resorted  to.  The  perchloride  is  perhaps  as  good  a 
preparation  as  any  other.  Ten  or  fifteen  drops  of  the  tincture  may  be 
given  with  one  grain  of  quinine  every  three  hours  to  a  child  five  years  of 


104  DISEASE   IN   CHILDREN. 

age.  Much,  larger  doses  of  the  drug  are  often  recommended  ;  but  young 
children  vary  greatly  in  their  capacity  for  benefiting  by  chalybeate  remedies, 
and  in  weakly  subjects  the  stomach  may  be  readily  deranged  by  an  excess 
of  the  medicine.  Now  it  is  of  the  first  importance  to  maintain  the  digestive 
power,  as  incomparably  the  best  tonic  for  a  child  is  nourishing  food. 

Instead  of  quinine,  chlorate  of  potash  is  often  conjoined  with  the  iron  ; 
but  this  remedy  should  be  given  with  caution  as  it  has  a  depressing  effect 
on  some  children.  It  is  well  to  begin  the  treatment  with  a  merciuial 
pru-ge,  such  as  gray  powder  with  jalapine,  but  the  aperient  need  not  be 
afterwards  repeated. 

In  the  use  of  local  remedies  we  have  to  fuMl  three  indications  :  to  arrest 
the  spread  of  the  false  membrane  ;  to  promote  its  removal,  and  to  prevent 
septicaemia  from  absorption  of  putrescent  matters  in  contact  with  the  tissues. 

Many  measures  have  been  employed  to  prevent  the  extension  of  the 
local  lesion  in  the  throat.  At  one  time  strong  cauterising  agents  were 
resorted  to  to  effect  this  purpose,  such  as  the  solid  nitrate  of  silver,  equal 
parts  of  strong  hydrochloric  acid  •and  honey,  and  the  strong  solution  of 
j)erchloride  of  ii-on.  The  repeated  use  of  these  agents  is  now  almost 
universally  condemned,  but  one  thorough  swabbing  of  the  throat  is  stiU 
advocated  hj  some  writers.  I  have  occasionally  employed  equal  parts  of 
strong  perchloride  of  iron  solution  and  glycerine,  and  have  thought  that 
used  efficiently,  once  for  all,  the  application  has  been  followed  by  benefit. 
Many  writers,  however,  deprecate  the  use  of  these  powerful  agents  ;  and 
certainly,  since  I  have  abandoned  their  employment,  I  have  not  found  the 
disease  less  tractable  or  more  dangerous  to  life. 

To  promote  the  hquefaction  or  removal  of  the  false  membrane  many 
agents  are  employed.  Rough  tearing  away  of  the  diphtheritic  exudation 
is  injuiious  as  w^ell  as  useless  ;  but  gentle  measures  to  further  its  destruc- 
tion are  decidedly  beneficial.  To  be  of  service,  however,  the  application 
must  be  used  repeatedly,  and  can  be  applied  with  perfect  efficiency  in  the 
form  of  a  spray  from  one  of  Siegels  spray  producers.  Lime-water,  alone 
or  with  carbolic  acid  (twenty  di-ops  to  the  ounce  of  lime-water),  licj.  potassse 
(twenty  drops  to  the  ounce  of  water),  boracic  acid  (a  scruple  to  the  ounce), 
lactic  acid  (twenty-six  gxains  to  the  ounce),  benzoate  of  soda  (one  scruple 
to  one  drachm  to  the  ounce),  all  these  are  of  service,  and  the  addition  of 
glycerine  (half  a  di-achm  to  the  ounce)  increases  the  efficacy  of  the  solu- 
tions. Lotions  of  chlorate  of  potash  (ten  grains  to  the  ounce)  and  of 
salicylic  acid  (three  or  four  grains  to  the  ounce)  are  praised  by  some,  as 
well  as  dry  insufflations  of  flour  of  sulphur,  of  alum,  and  of  tannin.  These 
latter  have,  however,  the  disadvantage  that  they  cannot  be  employed  with- 
out distressing  the  patient.  If  thought  more  desirable,  any  of  the  above 
liquid  preparations  may  be  used  with  a  brush,  but  this  method  of  em- 
ployment is  distressing,  and  except  perhaps  in  the  case  of  infants,  presents 
no  special  advantage. 

The  thii'd  indication,  viz.,  to  destroy  the  poisonous  products  of  putre- 
faction so  as  to  prevent  absorj^tion  and  blood  contamination,  is  partly 
affected  by  the  use  of  many  of  the  preceding  agents.  But  besides  these, 
si)ecial  disinfectants  may  be  sprayed  into  the  throat,  such  as  the  solution  of 
chlorinated  soda  or  hme  diluted  with  water  (half  a  di-achm  to  the  ounce), 
permanganate  of  potash  (five  gTains  to  the  ounce),  sulphui'ous  acid,  pure 
or  diluted  with  an  equal  quantity  of  water,  etc.  The  comfort  of  the  patient 
is  also  promoted  by  the  use  of  the  steam  kettle,  as  akeady  recommended, 
and  by  warm  applications  externally  to  the  throat.  If  the  child  be  old 
enough,,  he  may  be  allowed  to  suck  lumps  of  ice. 


DIPHTHERIA — TREATMENT  —  TRACHEOTOMY,  105 

In  nasal  diplitheria,  where  septicaemia  is  especially  to  be  dreaded,  the 
thorough  cleansing  of  the  nasal  passages  with  a  mild  disinfecting  solution 
should  never  be  omitted.  The  importance  of  this  measure  is  insisted  upon 
"by  Dr.  Jacobi,  who  recommends  that  the  process  should  be  carried  out  by 
the  fountain  syringe  wherever  practicable.  Failing  that,  an  ordinary  ear 
syringe  can  be  made  use  of.  He  directs  that  the  injection  should  be  re- 
peated as  often  as  every  hour,  and  that  if  the  obstructed  nostrils  i-esist  the 
passage  of  fluid,  the  coarser  matters  must  be  removed  by  a  jDrobe  or 
forceps.  Dr.  Jacobi  states  that  these  injections,  efficiently  employed,  give 
great  relief  to  the  patient  and  rapidly  reduce  the  size  of  the  swollen  glands. 
He  advises  a  warm  solution  of  carbolic  acid  (two  to  four  gxains  to  the 
ounce),  or,  if  there  is  no  foetor,  of  lime-water. 

When  the  disease  invades  the  larynx  the  danger  is  at  once  imminent, 
and  the  question  of  operative  interference  has  to  be  considered.  In  cases 
of  laryngeal  diphtheria  (true  membranous  croup),  tracheotomy  is  the  only 
hope  left  to  us — the  chUd's  last  chance  for  his  life.  Du-ectly,  therefore, 
"we  feel  sure  that  the  larynx  is  involved,  the  operation  should  be  under- 
taken without  unnecessary  delay.  It  must  be  remembered,  however,  that 
dyspnoea  alone  is  not  always  a  sufficient  indication  for  this  step.  As  has 
"been  before  explained  (see  p.  99),  hvidity  and  laboured  breathing  are  some- 
times due  to  an  impediment  to  the  circulation  of  blood  through  the  lungs. 
In  such  a  case  there  is  no  want  of  air,  and  opening  the  larynx  will  bring 
no  relief  to  the  child's  distress.  The  signs  by  which  these  two  very  differ- 
ent conditions  are  indicated  have  been  ah'eady  enumerated.  When,  there- 
fore, we  notice  that  the  respiratory  movements  have  become  laboured,  with 
great  recession  of  the  epigastrium  and  the  soft  parts  of  the  chest  in  inspi- 
ration ;  that  the  breathing  is  hissing  and  stridulous,  the  voice  whispering, 
and  the  cough  husky  and  stifled,  the  operation  should  be  no  longer  post- 
poned. We  have  nothing  to  hope  for  in  delay  ;  on  the  contrary,  the  earher 
the  tube  is  introduced  into  the  trachea,  the  sooner  will  the  child's  suffering 
be  relieved  and  the  better  be  his  prospect  of  a  cure.  The  success  which  often 
attends  the  operation  of  tracheotomy  in  membranous  croup  is  very  encour- 
aging, and  even  in  the  case  of  an  infant  we  should  not  hesitate  to  have  re- 
course to  it.  Even  at  a  later  stage,  when  the  child  seems  to  be  at  the  last 
gasp,  the  operation  should  still  be  undertaken,  for  nothing  short  of  actual 
death  can  render  it  hopeless. 

In  performing  the  operation,  if  the  asphyxia  is  far  advanced  antesthetics 
wiU  be  unnecessary.  If  the  lividity  is  not  marked,  chloroform  should  be  ad- 
ministered, and  if  the  child  be  made  to  inhale  it  gradually  so  that  he  does 
not  breathe  in  too  large  a  volume  at  first,  the  anaesthetic  may  be  given 
without  fear.  The  details  of  the  operation,  as  they  come  under  the  depart- 
ment of  the  surgeon,  need  not  be  here  referred  to  ;  more  especially  as  they 
will  be  found  recorded  at  length  in  all  works  on  practical  surgery.  It  may 
be  only  remarked  that  the  size  of  the  tube  to  be  employed  should  be  the 
largest  which  can  be  introduced  without  violence  ;  that  it  should  be  as 
short  as  is  consistent  with  safety  ;  and  that  before  its  introduction  the  tra- 
chea and  larynx  must  be  thoroughly  cleansed  by  introducing  a  feather 
soaked  in  a  warm  solution  of  carbonate  of  soda  through  the  opening.  The 
importance  of  this  precaution  has  been  strongly  insisted  upon  by  my  col- 
league Mr.  Parker  in  his  well-known  treatise. 

The  rehef  afforded  by  the  operation  is  usually  complete.  If  the  diffi- 
culty of  breathing  still  continues,  it  is  a  sign  that  the  trachea  is  obstructed 
below  the  opening,  and  that  there  is  probably  extension  of  the  false  mem- 
brane far  down  the  ramifications  of  the  bronchi. 


106  DISEASE   IlSr   CniLDEEN. 

The  after-conduct  of  these  cases  is  of  the  utmost  importance,  as  success 
depends  upon  judicious  nursing  and  scrupulous  attention  to  small  points 
of  treatment.  Our  object  is  to  fiu-nish  a  constant  supply  of  properly  pre- 
pared ail-  to  the  lungs.  The  utmost  care  has  therefore  to  be  taken  ta 
maintain  the  inspired  air  at  a  suitable  temperature  and  degree  of  mois- 
ture, and  to  see  that  the  tube  is  kept  in  place.  Moreover,  the  strength  of 
the  child  has  to  be  supported,  and  the  treatment  of  the  constitutional  dis- 
ease to  be  continued. 

The  child  should  remain  in  his  tent  bedstead,  in  a  room  of  the  temper- 
ature of  70°  ;  and  the  croup-kettle  must  be  kept  in  action  on  a  side  table 
so  as  to  moisten  the  air  he  breathes.  A  disinfectant  should  be  always  ad- 
ded to  the  water  in  the  boiler,  as  ah'eady  dh-ected.  The  kettle  must  not  be 
placed  too  near  the  bed.  If  the  ah"  is  kept  constantly  saturated  with  va- 
poTor,  the  excess  of  moisture  tends  to  depress  the  child.  Mr.  Parker's  rule 
is  a  good  one,  viz.,  that  we  should  be  guided  by  the  amount  of  tracheal 
secretion.     If  this  is  small,  the  amount  of  steam  can  be  increased. 

The  wind-pipe  and  tracheotomy  tube  must  be  kept  patent.  Free  se- 
cretion is  to  be  desired,  but  tliis  must  not  be  allowed  to  accumulate  so  as 
to  interfere  with  the  passage  of  ah*.  It  is  important  to  apply  weak  alkaUne 
solutions,  such  as  the  bicarbonate  of  soda  (ten  to  twenty  gTains  to  the 
ounce)  with  a  hand  sj)ray -producer  at  short  intervals,  so  that  the  inhaled  ah" 
may  be  saturated  with  the  solvent.  The  sjDray  at  once  produces  free  secre- 
tion into  the  windpipe  ;  and  the  repeated  use  of  this  agent  prevents  the 
mucus  from  accumulating  and  becoming  inspissated  so  as  to  block  up  the  air- 
passages.  It  is  curious  to  notice  how  the  dry  mucous  membrane  becomes 
almost  instantly  relieved  by  this  means.  After  a  few  minutes'  use  of  the 
spray,  a  feather  soaked  in  the  same  solution  must  be  passed  into  the  trachea 
through  the  silver  tube,  so  as  to  clear  away  loosened  membrane  and  mucus. 
The  introduction  of  the  feather  caiises  spasmodic  cough,  but  this  is  not 
to  be  regretted,  as  the  violent  expulsive  action  usuaUj^  relieves  the  j)atient  of 
large  portions  of  membrane,  and  greatly  aids  in  clearing  the  trachea.  If 
signs  of  obstructed  breathing  are  noticed  at  any  time,  we  may  conclude 
that  either  the  trachea  or  the  tracheotomy  tube  is  becoming  obstructed,  or 
that  the  latter  is  displaced.  Measures  must  then  be  taken  at  once  to  rem- 
edy the  fault. 

The  inner  tube  should  be  removed  every  hour  or  two  and  cleaned  with 
a  feather  dipjDed  in  the  warm  alkahne  solution.  The  outer  tube  will  re- 
quire cleaning  only  once  in  the  twenty-four  hours.  When  it  is  removed, 
advantage  should  be  taken  of  the  opportrmity  to  j)ass  the  moistened  feather 
upwards  into  and  through  the  glottis,  so  as  to  clear  the  upper  part  of  the 
windpipe.  At  this  time,  also,  the  wound  can  be  examined  for  any  un- 
healthy appearance.  As  a  rule,  the  outer  tube  can  be  easily  taken  out  and 
rej)laced,  for  the  tissues  around  the  opening  soon  become  matted  to- 
gether by  inflammatory  exudation,  and  the  orifice  remains  patent  after 
the  tube  is  withdrawn.  After  each  cleaning  the  tube  should  be  replaced 
by  another  of  different  length,  so  that  the  child  may  wear  a  short  and  a 
long  tube  alternately.  If  the  tube  be  of  silver,  it  should  be  examined  for 
black  discolourations,  as  these  are  due  to  morbid  action  at  the  corre- 
sponding part  of  the  wound,  and  will  therefore,  as  Mr.  Parker  has  pointed 
out,  be  often  valuable  guides  in  indicating  the  parts  to  which  our  attention 
should  be  directed. 

After  a  few  days,  when  fresh  membrane  has  ceased  to  be  formed,  we 
may  make  trial  from  time  to  time  of  the  child's  power  of  breathing  through 
the  glottis  by  closing  the  external  wound  with  a  finger.     At  first   the 


DIPHTHERIA — TREATMEISTT.  107 

breathing  is  laboured,  especially  in  inspiration,  but  in  most  cases  the 
glottis  soon  becomes  accustomed  to  act  agaia  as  an  au'-passage. 

"While  the  above  treatment  is  being  carried  out,  the  strength  of  the 
child  must  be  supported  by  judicious  feeding.  Strong  meat  essence, 
pounded  meat,  eggs,  milk,  strong  meat  broths  thickened  with  arrowi'oot 
or  sago,  and  flavoured  if  desired  mth  turnip,  should  be  given  at  regular 
intervals.  Sometunes  there  is  difficulty  in  persuading  the  child  wilhngly 
to  take  sufficient  nourishment  ;  and  sometimes  the  power  of  swallowing  is 
impaired  fi'om  paresis  of  the  muscles  of  the  pharynx.  Sometimes,  also, 
there  appears  to  be  loss  of  sensibihty  of  the  glottis,  so  that  articles  of  food 
taken  apjDcar  at  the  wound  in  the  au'-pipe.  If  necessary,  therefore,  food 
must  be  conveyed  to  the  stomach  by  an  elastic  tube  passing  through  the 
nose  (see  Introductory  Chapter,  page  15).  By  this  means  the  patient  can 
be  fed  efficiently  every  three  or  four  hours.  Internal  remedies,  with  the 
exception  of  alcohol,  are  better  discontinued  at  this  time.  It  is  wiser  to 
limit  ourselves  to  the  local  measures  which  have  been  described  for  the 
rehef  of  the  local  disease,  and  to  trust  to  regular  feediag  and  alcohol  to 
support  the  strength  of  the  patient  and  enable  him  to  struggle  successful- 
ly against  the  constitutional  disorder. 

The  tracheotomy  tube  should  not  be  allowed  to  remain  in  the  trachea 
a  day  longer  than  is  necessary ;  for  besides  that  it  is  not  well  to  allow  the 
glottis  to  continue  a  long  time  inactive,  too  persistent  retention  of  the  tube 
may  be  followed  by  ulceration  about  the  wound,  necrosis  of  the  rings  of 
the  trachea,  and  other  accidents.  In  finally  closing  the  wound  certain  dif- 
ficulties are  sometimes  met  with.  The  child  having  become  accustomed  to 
the  use  of  the  tube,  and  having  a  keen  recollection  of  his  sufferings  before 
its  insertion,  is  often  nervous  and  apprehensive  of  a  retiu'n  of  his  dyspnoea. 
This  very  dread  may  be  sufficient  to  interfere  with  the  normal  action  of 
the  laryngeal  muscles.  Before  removing  the  tube  altogether  many  at- 
tempts should  be  made,  by  withdi-awing  it  temporarily  and  closing  the 
opening  with  a  pad  of  lint,  to  accustom  the  child  to -breathe  without  its 
help.  He  should  be  also  made  to  articulate  under  the  same  conditions  {i.e., 
while  the  opening  is  closed),  so  as  to  bring  the  muscles  of  his  larynx  agaia 
into  action. 

The  accidents  which  often  interfere  seriously  with  the  final  withdrawal 
of  the  tube  are  :  inflammatory  hypertrophy  of  the  vocal  cords,  adhesion 
between  the  cords,  granulations  growing  from  the  tracheal  wound  or 
from  the  posterior  wall  of  the  windpipe,  paralysis  of  the  posterior  crico- 
aryteenoid  muscles,  spasm  of  the  glottis,  cicatricial  narrowing  of  the  trachea. 
Sometimes  it  is  only  after  much  difficulty  that  the  proper  function  of  the 
disused  larynx  is  restored.  Such  cases  are,  however,  exceptional.  Usually 
after  a  few  days  the  child  becomes  accustomed  to  do  without  the  help  of 
the  tube  and  aU  apprehensions  of  a  return  of  his  dyspnoea  may  be  laid 
aside. 

The  chief  danger  and  common  cause  of  death  after  tracheotomy  in 
membranous  croup  is  the  occurrence  of  pneumonia.  If  this  unfortunate 
complication  arise,  warm  poultices  must  be  kept  constantly  apphed  to  the 
chest,  and  stimulants  must  be  given  freely. 

If  diphtheria  of  the  external  wovmd  occur,  it  is  best  treated  by  a  care- 
ful attention  to  cleanliness,  and  by  painting  the  wound  with  a  solution  of 
lactic  acid  (twenty-four  grains  to  the  ounce). 

In  the  paralysis  which  often  follows  diphtheria  the  child  shordd  be  re- 
moved to  a  bracing  sea-side  residence,  and  while  there  should  be  regularly 
shampooed  and  be  given  baths  of  the  sea- water.     If  a  dip  in  the  sea  is  too 


108  DISEASE  IN   CHILDEEN. 

yigorous  a  shock  for  his  weakened  frame,  the  douche  may  be  employed  in 
the  house  after  suitable  preparation,  as  directed  elsewhere  (see  Introductory 
Chapter,  page  17).  Quinine,  iron,  and  strychnia  are  useful  in  these  cases, 
and  the  child  should  pass  as  much  time  as  possible  out  of  doors.  Regular 
faradisation  is  of  service,  especially  in  cases  where  the  loss  of  power  affects 
the  muscles  of  the  larynx  or  those  employed  in  respiration.  In  cases  where 
there  is  complete  paralysis  of  the  muscles  of  deglutition,  and  consequent 
inability  to  swallow,  the  child  must  be  fed  regularly  with  the  stomach-tube 
]3assed  through  the  nose.  At  the  East  London  Children's  Hospital  many 
children  have  been  saved  by  this  means  who  were  quite  unable  to  take 
nourishment,  and  who  without  this  help  would  certainly  have  died  of  in- 
anition. 

When  a  thrombus  forms  in  the  heart  and  gives  ries  to  serious  dyspnoea, 
the  child  should  be  kept  lying  doivn  ;  hot  bottles  should  be  applied  to  his 
feet  and  if  necessary  to  his  sides  ;  and  diffusible  stimulants  must  be  given 
internally.  Dr.  Eichardson  speaks  highly  of  the  liq.  ammonise  (P.  B.),  of 
which  a  few  drops  may  be  given  with  five  grains  of  iodide  of  potassium 
every  alternate  hour.  If  the  heart's  action  appear  to  be  failuig,  stimulants 
in  large  and  repeated  doses  are  indicated. 


CHAPTER  XI. 

ERYSIPELAS. 

Erysipelas  is  not  often  seen  in  diildhood  after  the  age  of  infancy  has 
passed.  For  a  short  time  after  birth,  however,  there  appears  to  be  a  special 
tendency,  under  favouring  conditions,  to  suffer  from  this  serious  affection  ; 
and  in  lying-in  hospitals  the  disease  is  a  not  unfamiliar  one.  Amongst 
vyell-to-do  families  erysipelas  but  rarely  attacks  the  infant,  and  in  chil- 
dren's hospitals,  even  in  those  where  quite  young  infants  are  admitted,  it 
is  exceptional  to  meet  with  an  example  of  this  form  of  illness. 

Causation. — Erysipelas  is  in  all  cases  a  general  disease  of  which  the 
dermatitis  and  its  consequences  are  merely  the  local  expression.  The^ 
malady  most  commonly  affects  new-born  babies  at  a  time  when  puerperal 
fever  is  prevalent,  and  is  most  liable  to  happen  during  the  first  six  weeks. 
of  life.  It  is  then  apparently  the  result  of  a  similar  affection  to  that  whick 
attacks  the  mother ;  and  the  illness  almost  invariably  has  a  fatal  issue. 
According  to  Trousseau,  besides  erysipelas,  purulent  ophthalmia  and  in- 
fective peritonitis  are  common  under  the  same  conditions,  and  the  three 
diseases  must  be  regarded  as  various  manifestations  in  different  subjects 
of  the  same  morbific  principle. 

But  besides  special  puerperal  infection,  other  agencies  will  act  as  pre- 
disposing causes  of  the  affection.  Unhealthy  conditions  generally  will  do 
this  ;  and  the  complaint  has  been  known  to  follow  exhausting  derange- 
ments and  diseases,  such  as  chronic  digestive  troubles  and  the  acute  spe- 
cific fevers.  In  some  cases,  however,  no  such  influences  can  be  discovered 
to  have  been  in  operation.  Such  a  case  came  under  my  own  observation 
in  my  student  days.  A  healthy  infant  of  a  week  old  had  great  difficulty 
in  relieving  his  bladder,  owing  to  a  very  narrow  preputial  orifice.  The 
operation  for  circumcision  was  performed  (not  very  wisely)  by  a  young 
surgeon.  Extensive  erysipelas  followed,  starting  from  the  wound,  and  in 
a  few  days  resulted  in  the  death  of  the  patient.  The  child  was  being- 
suckled  by  a  healthy  mother.  The  parents  were  of  the  poorer  class,  but 
seemed  comfortably  circumstanced  ;  and  their  residence  was  clean,  and 
certainly  presented  no  obvious  insanitary  conditions.  Possibly  in  this 
and  similar  cases  the  erysipelas  owed  its  origin  to  the  use  of  imperfectly 
cleansed  instruments  in  the  oj^eration. 

The  exciting  cause  of  the  affection  is  usually  traumatic.  The  erysipelas, 
may  follow  the  operation  of  vaccination,  inflammation  set  up  about  the 
umbilicus,  a  burn,  or  the  incautious  application  of  a  blister.  It  may  de- 
velop around  an  intertrigo  or  attack  a  surface  excoriated  by  the  irritation 
of  excreta.  Some  time  ago  a  local  outbreak  of  erysipelas  occui-ring  in  a  jDar- 
ticular  London  district  was  traced  to  the  use  of  a  violet  powder  extensively 
adulterated  with  white  arsenic.  Apparently  idiopathic  cases  do,  however, 
sometimes  occur.     Thus,  Mr.  Strugnell  has  reported  the  case  of  a  male  in- 


110  DISEASE   IN   CHILDEEN". 

fant,  aged  eight  weeks,  in  whom  a  patch  of  erysipelas  appeared  on  the 
scalp  and  thence  spread  to  the  face,  arms,  and  trunk.  The  child  had  suf- 
fered from  no  bruise  or  other  injuiy,  and  nothing  objectionable  was  dis- 
covered in  the  sanitary  state  of  the  house  in  which  his  parents  were  living. 
Other  cases  of  a  similar  kind  are  on  record. 

It  seems  possible  that  the  milk  of  a  mother  who  has  lately  suffered  from 
erysipelas  may  communicate  the  disease  to  her  sucking  child.  Dr.  Schole- 
field  has  reported  a  case  in  which  a  woman  during  a  sharp  attack  of  ery- 
sipelas of  the  face,  neck,  and  scalp,  gave  birth  to  a  son.  As  the  labour 
progressed  the  erysipelas  gradually  faded,  and  when  the  child  was  born  no 
trace  of  redness  remained.  The  mother  was  warned  not  to  nurse  her 
child  ;  but  on  the  fourth  day,  as  the  secretion  of  milk  was  copious,  she 
put  the  infant  to  the  breast.  Twelve  houi-s  afterwards  a  red  blush  ap- 
peared on  the  child's  thumb  and  spread  to  the  arm.  This  faded  and  the 
opposite  arm  became  affected  in  the  same  way.  Afterwards  the  same 
symptom  appeared  on  one  of  the  lower  limbs,  and  in  the  end  a  large  ab- 
scess formed  over  the  sacrum  and  the  child  died.  The  mother  had  no  re- 
turn of  the  erysipelas  after  deliver3% 

This  was  not  a  case  of  puerperal  erysipelas  in  the  mother,  for  the  dis- 
ease had  not  only  preceded  labour  but  had  completely  disappeared  by 
the  time  the  child  was  born.  It  seems  23robable  that  the  poison  was  com- 
municated by  the  mother  to  the  infant  through  the  milk  from  her  breast. 
At  any  rate,  it  is  difficult  to  say  in  what  other  way  the  infant  could  have 
contracted  the  disease. 

Morhid  Anatomy. — In  the  skin  the  inflamed  surface  is  red,  hard,  and 
brawny,  -with  a  well-defined  margin.  The  redness  disappears  on  jjressure, 
and  the  hardness  is  due  to  accumulation  of  serum,  lymph,  and  corpuscles 
in  the  substance  of  the  cutis  and  tissue  beneath  it.  If  the  oedema  be  co- 
pious, the  part  is  dull  red  in  colour,  soft  to  the  touch,  and  pits  on  pressure. 
The  area  of  inflammation  rapidly  extends  to  neighboiuing  parts,  and  as  it 
spreads  the  skin  first  attacked  becomes  less  tense  and  browner  in  colour. 
Sometimes  the  skin  affection  disajDpears  from  one  part  of  the  body  and 
reappears  on  another  without  spreading  along  the  surface.  Thus,  it  may 
attack  one  limb,  then  fade  in  its  first  situation  and  break  out  on  the  cor- 
responding limb  of  the  opposite  haK  of  the  body. 

As  a  result  of  the  inflammation,  abscesses  may  form  in  the  subcutane- 
ous tissue  ;  and  sometimes  sloughing  may  occur  in  the  skin  or  areolar  tis- 
sue. Often  vesicles  or  bullse  form  on  the  inflamed  surface,  especially  in 
the  severe  cases  where  there  is  subcutaneous  sloughing. 

In  most  instances  of  erysipelas  in  the  infant,  adjacent  parts  share  in  the 
inflammation  of  the  skin.  Peritonitis  is  common,  even  when  the  dermatitis 
does  not  occupy  the  abdominal  parietes.  There  may  be  also  inflammation 
of  other  serous  membranes — the  pleura,  the  pericardium,  and  the  cerebral 
meninges.  Sometimes  the  inflammation  spreads  from  the  skin  to  other 
parts  by  direct  continuity.  Thus,  it  may  pass  into  the  ear  by  the  auditory 
meatus,  into  the  nose  and  throat  by  the  mouth,  nares,  and  lachrymal  ducts. 
In  other  cases,  the  disease  begins  in  these  deeper  parts  and  extends  to  the 
skin  by  the  same  channels.  In  addition  to  the  above  morbid  appearances, 
evidence  of  phlebitis,  pneumonia,  and  enteritis  is  often  observed.  Lately 
micrococci,  arranged  in  clusters,  have  been  discovered  by  Fehleison  in  the 
lymphatic  vessels  of  the  affected  portions  of  the  skin.  This  observer  has 
even  succeeded  in  artificially  cultivating  the  organisms  on  gelatine,  and  in 
the  course  of  two  months  reared  fourteen  generations  of  micrococci.  Some 
of  thes6  cultivated  micro-orf?anisms  he  inoculated  into  animals  and  others 


ERYSIPELAS — MOEBID   ANATOMY — SYMPTOMS.  Ill 

into  the  human  subject.  In  almost  all  cases  a  typical  eiysipelas  followed 
the  operation  in  the  person  or  animal  experimented  upon. 

Syirqjtoms. — The  disease  presents  different  characters  according  to 
whether  it  arises  as  a  consequence  of  puerperal  infection  or  is  induced  by 
other  causes. 

In  the  first  case  the  general  symptoms  are  usually  violent  from  the 
first.  A  patch  of  bright  redness  appears  on  some  part  of  the  abdomen, 
usually  about  the  pubes.  The  part  looks  somewhat  swollen,  feels  hard 
and  brawny,  and  has  a  well-defined  margin.  The  patch  may  be  of  limited 
extent,  but  there  is  high  fever,  and  the  infant  looks  ill,  is  restless,  cries 
frequently,  and  is  evidently  in  great  jpain-  By  the  next  day  the  area  of 
redness  has  become  widened  ;  the  fever  continues  ;  the  fontanelle  is  de- 
pressed, and  the  patient  sleeps  little  and  is  very  restless  and  feeble.  The 
erysipelas  continues  to  extend.  It  passes  downwards  to  the  lower  limbs 
and  upwards  over  the  trunk  ;  the  belly  usually  becomes  fuller  and  may  be 
tympanitic  ;  vomiting  and  diarrhoea  come  on,  and  a  jaundiced  hue  of  the 
skin  may  be  observed.  After  a  few  days,  the  child  falls  into  a  state  of 
collapse  and  death  may  be  preceded  by  convulsions  and  coma.  In  this 
form  of  the  disease  the  duration  is  sometimes  very  short.  A  child  who 
appears  to  be  healthy  and  vigorous  when  first  attacked  rapidly  falls  into  a 
state  of  prostration  and  may  die  in  a  few  days.  The  illness  may,  however, 
last  for  a  longer  time.  The  colour  of  the  inflamed  surface  then  becomes 
deeper  and  more  purple,  buUse  appear  on  the  surface,  abscesses  form  in 
the  subcutaneous  tissue,  or  gangrenous  sloughs  may  destroy  considerable 
portions  of  the  skin.  Infants  attacked  by  the  puerperal  form  of  erysipelas 
are  usually  under  two  weeks  old,  and  the  illness  is  almost  invariably 
fatal. 

"When  erysipelas  occurs  as  a  result  of  other  causes  than  puerperal  in- 
fection the  early  symptoms  are  less  violent.  The  local  afl'ection  generally 
begins  about  the  genitals,  the  pubes,  the  anus,  or  the  lower  part  of  the 
abdomen,  and  sjpreads  thence  in  various  directions.  When  it  extends 
widely,  the  parts  of  the  skin  first  affected  become  paler,  but  are  liable  at 
any  time  to  a  return  of  the  redness.  The  child  has  a  pale  pinched  face, 
but  may  continue  to  take  his  food,  and  his  digestion  is  often  fairly  good. 
In  other  cases,  he  refuses  the  bottle  or  breast,  and  may  be  troubled  with 
frequent  vomiting  or  looseness  of  the  bowels.  The  temperature  is  high, 
at  night  it  rises  to  103°  or  105°,  sinking  to  101°  or  102°  in  the  morning. 

Complications  often  occur  in  these  cases.  Abscesses  may  form  in 
various  parts  of  the  body  ;  gangTenous  sloughing  may  attack  the  skin ; 
pneumonia  may  occur  ;  or  the  inflammation  may  pass  directly  to  the  peri- 
toneum through  the  recently  healed  umbilicus,  or  to  the  larynx  and  throat. 
An  infant  under  six  months  old  was  brought  to  St.  Thomas'  Hospital  and 
admitted,  under  Mr.  Croft,  for  erysipelas  following  vaccination.  When 
seen,  the  whole  cervical  region  and  part  of  the  chest  were  the  seat  of  oede- 
matous  erysipelas,  and  there  was  great  dyspnoea  without  symptoms  of 
croup.  The  child  was  placed  in  a  warm  bath  and  a  dose  of  ipecacuanha 
wine  was  given  to  produce  vomiting.  These  measures  relieved  the  child 
for  a  time,  but  in  the  evening  the  dyspnoea  returned  with  such  intensity 
that  tracheotomy  was  performed  by  the  Surgical  Eegistrar.  After  the  op- 
eration the  infant  coughed  up  small  pieces  of  cartilage — probably  from  the 
rings  of  the  trachea.     Eventually  he  recovered. 

Whether  the  disease  be  idiopathic  or  arise  from  traumatic  causes  its 
gravity  appears  to  be  the  same.  In  the  first  case  the  appearance  of  the 
special  symptoms  is  often  preceded  by  signs  of  derangement  or  sluggish- 


112  *  DISEASE  IjS"   CHILDEEN. 

ness  of  the  digestive  organs.  In  Mr.  Strugnell's  case,  before  referred  to, 
an  infant  of  eight  weeks  old  had  been  a  fauiy  healthy  child,  but  for  ten 
days  or  so  had  been  passing  very  firm,  pale,  pasty-looking  motions.  The 
child  was  suddenly  taken  with  severe  symptoms,  and  when  first  seen  was 
lying  with  his  head  thrown  back  and  his  thiunbs  twisted  inwards  upon 
his  palms,  but  there  was  no  retraction  of  the  abdomen  or  strabismus. 
The  pupils  were  equal  and  acted  to  hght,  the  pulse  was  rapid,  the  temper- 
ature was  normal.  On  examination  sHght  cedema  of  the  scalp  was  noticed 
on  the  occipital  bone,  but  there  was  no  redness.  On  the  next  day  the 
cedematous  part  was  red.  On  the  thiixl  day  the  cerebral  symptoms  had 
subsided  ;  but  the  erysipelas  had  spread  to  the  forehead  and  down  the 
back  of  the  neck.  Afterwards  it  extended  over  the  face,  arms,  and  trunk. 
A  vesicle  the  size  of  a  filbert  and  filled  with  clear  serum  formed  over  the 
left  elbow,  and  another  appeared  a  little  later  on  the  thigh.  As  the  dis- 
ease advanced,  the  abdomen  became  distended  and  tympanitic,  and  the 
breathmg  oppressed.  No  mischief  was  discovered  in  the  chest.  The  child 
sank  and  died  on  the  seventh  day. 

In  this  case  the  early  cerebral  symptoms  (retraction  of  the  head  and 
twisting  in  of  the  thumbs)  were  probably  symptomatic  of  the  general  dis- 
ease and  not  of  any  special  intra-cranial  complication.  They  were  of  short 
diu"ation  and  quickly  disappeared  when  the  skin  affection  became  marked. 
The  tympanites  and  embarrassment  of  breathing  were,  no  doubt,  due  to  the 
occurrence  of  peritonitis.  Premonitory  symptoms,  such  as  were  found  in 
the  above  instance,  are  not  common.  Usually  the  first  indication  of  ill- 
health  is  the  occurrence  of  the  cutaneous  redness  and  swelling. 

In  traimiatic  cases  the  duration  of  the  disease  is  often  considerable. 
The  illness  may  last  two  or  three  weeks,  or  even  longer.  Eecovery  is  not 
a  frequent  termination,  and  usually  death  is  brought  about  by  one  of  the 
many  comphcations  to  which  these  cases  are  hable.  If  none  of  these  occur, 
the  case  may  end  favourably,  even  although  the  erysipelas  has  spread  ex- 
tensively and  involved  the  greater  part  of  the  surface  of  the  body.  The 
subsidence  of  the  cutaneous  inflammation  is  followed  by  desquamation  of 
the  epithehum  in  the  portions  of  skin  affected. 

Diagnosis. — The  nature  of  the  disease  can  scargely  be  misapj)rehended. 
A  patch  on  the  skin  of  bright  redness,  which  feels  brawny  to  the  touch  and 
is  j)erhaps  cedematous,  spreads  continuously  over  the  surface,  and  is  bounded 
by  a  well-defined  margin — these  local  symptoms  combined  with  the  severe 
general  disturbance  and  high  fever,  make  the  diagnosis  of  erysipelas  an 
easy  matter. 

Prognosis. — When  erysipelas  occiu's  in  an  infant  of  a  week  or  fortnight 
old,  as  a  result  of  puerperal  infection,  the  prognosis  is  most  serious.  Very 
few  of  these  cases  recover,  although  Trousseau  has  stated  that  in  cases 
where  abscesses  have  formed  extensively,  and  in  these  cases  only,  he  has 
known  life  to  be  saved.  Consequently  he  regarded  the  occurrence  of  ab- 
scesses as  by  no  means  an  unfavourable  symptom. 

When  the  disease  arises  as  a  result  of  other  causes  the  chOd's  pros- 
pects are  more  hopeful,  and  are  brighter  in  proportion  to  his  age,  his 
general  strength,  and  the  healthfulness  of  his  surroundings.  Of  forty- 
thi-ee  cases  collected  by  Dr.  Lewis  Smith  eighteen  recovered  ;  but  of  the 
cases  of  recovery  in  only  one  was  the  child  yoimger  than  thi-ee  months. 
If  the  disease  attack  an  infant  during  the  first  two  or  three  weeks  after 
birth,  death  is  almost  certain.  After  the  age  of  six  months  the  proportion 
of  recoveries  is  greater  than  that  of  the  deaths. 

In  all  cases  the  occurrence  of  a  serious  complication  greatly  reduces  the 


EKTSIPELAS — TEEATMENT.  113 

child's  chances  of  escape,  and  if  peritonitis  occui*,  we  can  have  little  hope 
of  a  favourable  issue. 

Ti^eatment .  — In  cases  where  the  disease  arises  from  puerj^eral  infection 
treatment  has  been  found  of  little  value.  Alcoholic  stimulation  and  the  ad- 
ministration of  ammonia  and  bark  may  be  useful  in  supporting  the 
strength,  but  local  treatment  of  every  kind  appears  to  be  useless.  It 
would  be  advisable  in  these  cases  to  make  trial  of  benzoate  of  soda — a  salt 
which  has  been  higiily  praised  by  Dr.  Lehnebach  for  its  value  in  puer- 
peral fever  in  the  adult.  Two  or  three  grains  might  be  given  to  a  child  of  a 
week  old  every  four  hours,  and  if  the  fever  were  very  high,  one  or  two  grains 
of  quinine  might  be  added  once  in  the  day  to  a  dose  of  the  benzoate. 

In  cases  where  no  puerperal  infection  is  suspected,  the  child  should  be 
made  to  take  the  tincture  of  perchloride  of  iron  in  frequent  doses.  For  an 
infant  of  three  months  old  five  drops  of  the  remedy  may  be  given  in  gly- 
cerine every  four  hours.  At  the  same  time  the  strength  should  be  su]p- 
ported  by  a  careful  diet.  If  the  child  be  at  the  breast,  the  mother's  milk 
is  no  doubt  the  best  food  he  can  take.  In  addition,  he  may  have  a  tea- 
spoonful  of  the  brandy-and-egg  mixture  two  or  thi'ee  times  a  day  if  his 
fontanelle  is  greatly  depressed.  As  long,  hoAvever,  as  the  strengih  contin- 
ues good  there  is  no  necessity  for  stimidation.  If  the  j)atient  be  hand-fed, 
care  should  be  taken  that  his  milk  is  diluted  with  barley-water  or  thickened 
with  gelatine  ;  and  the  stools  must  be  inspected  to  see  that  undigested 
curd  is  not  passing  away  from  the  bowels.  If  this  be  so,  the  milk  should 
be  dUuted  with  half  its  bulk  of  barley-water  or  aq.  calcis ;  and  should  be 
aromatised  by  the  addition  of  two  teaspoonsful  of  an  aromatic  water  to  the 
bottle.     Mellin's  food,  white  wine  whey,  etc.,  may  also  be  given. 

With  regard  to  local  treatment,  innumerable  applications  have  been 
recommended.  Most  of  these  are  sedative  or  antiseptic.  Thus,  the  in- 
flamed part  may  be  anointed  with  an  ointment  composed  of  equal  parts 
of  extract  of  belladonna  and  glycerine,  and  covered  with  cotton  wool.  The 
appHcation  of  oil  of  turpentine  has  been  recommended  by  Hastreiter. 
Cavazzani  speaks  highly  of  brashing  the  surface  with  a  lotion  composed  of 
one  part  each  of  camphor  and  tannin  to  eight  parts  of  ether.  Painting 
with  tincture  of  iodine  is  advocated  by  some,  and  with  a  solution  of  car- 
bolic acid  by  others.  Heppel  states  that  the  spread  of  the  inflammation 
may  be  limited  by  painting  the  skin  at  the  circumference  of  the  j)atch,  and 
for  a  finger's  breadth  on  each  side  of  it,  with  a  ten  per  cent,  solution  of 
carboHc  acid.  The  brush  should  be  used  until  a  distinct  staining  of  the 
integument  has  been  produced.  The  plan  recommended  by  Hueter,  of  in- 
jecting subcutaneously  around  the  margin  of  the  j)atch  a  three  per  cent, 
solution  of  carbolic  acid,  is  inadmissible  in  the  case  of  a  young  child,  in 
whom  symptoms  of  carbolic  acid  poisoning  would  be  easUy  produced.  En- 
deavors to  limit  the  spread  of  the  erysipelas,  by  a  line  drawn  on  the  skin  with 
nitrate  of  silver  just  beyond  the  margin  of  the  inflamed  patch,  have  been 
found  to  be  useless.  In  the  child  such  a  proceedmg  is  to  be  strongly  dep- 
recated, as  its  employment  has  been  sometimes  knoANoi  to  lead  to  the  for- 
mation of  troublesome  sores  upon  the  surface. 

An  important  element  in  the  treatment  appears  to  be  covering  the  in- 
flamed surface  from  the  air.  Recently,  Mi-.  BarweU,  reviving  an  old 
method,  has  found  the  utmost  benefit  to  result  fi'om  covering  the  affected 
area  with  a  thick  coating  of  common  white  lead  house-paint,  renewing  the 
application  as  often  as  any  crack  appears  on  the  sui-face  of  the  paint.  This 
plan  of  treatment  seems  not  only  to  relieve  the  pain  quickly,  but  also  to 
reduce  the  temperature  and  favourably  influence  the  general  symptoms. 


CHAPTEEXIL 

WHOOPING-COUGH. 

"Whooping-cough,  or  pertussis,  is  an  infectious  disorder  in  which  catarrh  of 
the  air-passages  is  combined  with  nervous  symptoms  which  may  assume 
very  serious  proportions.  The  aifection  occurs  in  epidemics  and  may  at- 
tack the  youngest  infants  :  indeed,  sometimes  it  appears  immediately  after 
birth.  Iq  such  young  children  whooping-cough,  even  when  not  of  a  grave 
tyjDe,  may  cause  serious  consequences.  It  is  principally  dangerous,  how- 
ever, through  its  complications.  These  are  numerous,  and  often  appear 
towards  the  end  of  the  disease,  when  the  patient's  strength  is  reduced  by 
the  length  and  severity  of  his  illness. 

Causation. — The  disease  usually  occurs  in  epidemics,  and  appeal's  to  be 
eminently  infectious.  The  channel  of  infection  is  the  breath  and  expecto- 
ration ;  and  the  vii-us  is  capable  of  being  conveyed  by  the  atmosphere  or 
even  by  the  clothes.  Children  of  all  ages  are  very  susceptible  to  the  infec- 
tious principle.  The  disease  is  excessively  common  under  two  years  of 
age,  very  common,  even,  during  the  first  twelve  months.  Unfortunately, 
I  have  kept  no  systematic  record  of  the  many  cases  of  whooping-cough, 
which  have  passed  under  my  notice,  but  in  eighty-nine  cases  of  which  I 
have  preserved  notes  no  less  than  twenty-four  occurred  in  infants  during 
the  first  year  of  life.  Even  this  proportion  probably  represents  imperfectly 
the  frequency  of  the  disease  in  young  babies  ;  for  in  such  subjects  the 
spasmodic  stage  is  often  absent.  Dr.  E.  J.  Lee  is  of  opinion  that  infants 
suffer  from  pertussis  much  more  frequently  than  is  supposed,  and  asserts 
that  in  a  ver}'  young  child  a  whoop  ought  rather  to  excite  surprise  than  to 
be  looked  upon  as  an  ordinary  symptom.  This  is,  perhaps,  an  extreme 
statement,  but  there  is  no  doubt  that  in  infants  the  disease  frequently  as- 
sumes the  form  of  an  obstinate  pulmonary  catarrh  with  but  little  laryngeal 
spasm.  After  the  tenth  year  the  disease  becomes  very  rare  ;  but  it  may  be 
seen  at  any  time  of  life,  even,  as  is  well  known,  quite  at  the  close  of  ex- 
treme old  age. 

Whooping-cough  seems  to  be  more  common  in  the  spring  and  autumn 
than  in  the  other  seasons  of  the  year,  and  the  epidemic  is  often  found  to 
precede  or  to  follow  quickly  upon  an  epidemic  of  measles.  A  patient  who 
has  passed  through  one  attack  of  whooping-cough  is  in  little  danger  of  his 
illness  being  repeated,  for  a  second  attack  in  the  same  subject  is  rare. 
The  infection,  however,  lasts  for  a  considerable  time  after  the  whoop  has 
ceased  to  be  heard.  Dr.  Squire  is  of  opinion  that  at  least  six  weeks  shotdd 
be  allowed  to  elapse  before  the  patient  can  be  trusted  to  associate  with 
healthy  children. 

Pathology. — Examination  of  the  body  in  a  fatal  case  of  pertussis  reveals 
nothing  to  account  for  the  special  nervous  symptoms  which  impart  its  most 
characteristic  feature  to  the  disease.  We  find  signs  of  catarrh  of  the  air- 
passages,  viz.,  congestion  with  hypersecretion  of  the  mucous  membrane 


AVH00PI2s^G-C0UGH — PATHOLOGY — SYMPTOMS.  115 

within  the  glottis,  of  the  trachea,  and  of  the  bronchi  and  their  ramifica- 
tions. We  also  find  certain  consequences  produced  by  violence  of  cough 
and  spasm,  viz.,  pulmonary  collapse  and  emphysema.  In  addition,  we 
usually  meet  with  some  other  morbid  changes  due  to  the  complication  by 
means  of  which  the  fatal  issue  has  been  brought  about.  Thus,  there  may 
be  serious  congestion  and  even  extravasation  of  blood  into  or  upon  the 
brain,  and  sometimes  signs  of  thrombosis  of  the  intracranial  sinuses, 
shown  by  colourless  clots  of  laminated  structure  adhering  to  the  walls. 
The  lungs  may  be  the  seat  of  catarrhal  pneumonia,  and  occasionally  small 
extravasations  are  seen  here  as  in  the  brain.  Moreover,  there  is  almost  in- 
variably enlargement  of  the  bronchial  glands,  and  the  under  surface  of  the 
tongue  may  be  ulcerated  more  or  less  extensively. 

No  satisfactory  explanation  has  yet  been  given  of  the  real  nature  of  the 
complaint.  That  the  disease  is  due  to  inflammation  of  the  pneumogastric 
nerve  has  been  shown  to  be  erroneous.  Pressure  upon  the  same  nerve  by 
enlarged  glands  may  be  rejected  for  the  same  reasons  which  render  this 
explanation  of  the  phenomena  of  laryngismus  stridulus  an  insufficient  one. 
In  some  respects  the  aifection  resembles  a  zymotic  disease  ;  in  others  a 
neurosis.  Some  writers  consider  the  complaint  a  purely  catarrhal  one ; 
others  lay  most  stress  upon  the  nervous  symptoms.  That  the  disease  is 
something  more  than  a  mere  catarrh  is  shown  by  the  infectious  nature  of 
the  secretion  thrown  off  by  the  mucous  membrane.  In  1870  Letzerich 
believed  he  had  discovered  a  species  of  fungus  in  the  sputum,  and  sup- 
posed that  this  was  the  morbid  material  which,  carried  from  one  person  to 
another,  settled  upon  the  mucous  membrane  of  the  air-passages,  and  by 
its  irritation  gave  rise  to  the  spasmodic  symptoms.  Other  observers, 
however,  have  not  confirmed  this  alleged  discovery.  More  lately  Dr. 
Carl  Burger,  of  Bonn,  has  described  a  bacillus  which  he  has  found  in  the 
expectoration  of  children  suifering  from  whooping-cough,  and  states  that 
it  is  pecuhar  to  this  comj^laint. 

The  neurotic  character  of  pertussis  is  shown  not  only  by  the  laryngeal 
spasm,  but  by  the  violent  agitation  into  which  the  child  is  thrown  during 
a  paroxysm.  When  he  feels  the  desire  to  cough  becoming  irresistible  he 
clutches  at  his  mother's  dress  or  the  nearest  object  capable  of  giving  sup- 
port, and  his  whole  body  is  agitated  by  a  convulsive  trembling.  This  agi- 
tation is  usually  attributed  to  terror,  but  it  is  more  probably  the  conse- 
quence of  a  general  nervous  commotion  which,  carried  to  a  higher  pitch, 
may  become  a  genuine  convulsive  seizure.  A  distinguished  physician  who 
was  attacked  by  whooping-cough  after  middle  life,  in  describing  the  ner- 
vous agitation  induced  by  the  spasm,  assured  me  that  in  the  paroxysm  he 
required  all  his  self-control  to  avoid  beating  with  his  feet  upon  the  floor. 
It  seems,  therefore,  that  the  neurotic  element  of  the  disease  is  something- 
more  than  a  mere  nervous  spasm  of  the  larynx  and  diaphragm.  There 
appears  to  be  a  general  agitation  of  the  whole  nervous  system,  which  may 
be  more  or  less  pronounced  according  to  the  severity  of  the  attack  and 
the  inherent  susceptibility  of  the  child. 

Symptoms. — The  incubation  period  of  pertussis  is  difficult  to  ascertain 
on  account  of  the  uncertainty  as  to  the  exact  day  upon  which  the  disease 
can  be  said  to  begin.  It  has  been  estimated  at  from  two  to  seven  days. 
Other  observers  are  of  opinion  that  it  may  last  a  fortnight. 

When  the  disease  begins  we  find  the  symptoms  of  catarrh  of  the  air- 
passages.  The  eyes  are  slightly  injected,  there  is  snuffling  and  increased 
secretion  from  the  nose,  and  the  child  soon  begins  to  cough.  There  is 
some  fever,   the  temperature  usually  rising   to   100°,  and   the  pulse   is 


116  DISEASE   I]Sr   CHILDEElSr. 

quickened.  In  a  day  or  two  there  may  be  in  addition  some  increased 
rapidity  of  breathing.  If  the  catarrh  affect  the  gastric  mucous  membrane, 
there  is  loss  of  appetite  and  the  child  may  be  lang-uid  and  mope.  The 
symptoms  resemble  those  of  an  ordinary  catarrh,  but  their  specific  charac- 
ter may  be  sometimes  detected  by  noticing  the  unusual  obstinacy  of  the 
cough.  It  is  repeated  at  yeiy  short  intervals,  and  sometimes  is  almost  in- 
cessant. This  catarrhal  stage  lasts  for  a  yariable  time.  It  may  occupy 
only  a  few  days  or  may  be  continued  for  several  weeks.  The  symptoms 
usually  increase  in  severity  as  the  days  go  by.  The  cough  becomes  more 
troublesome,  and  is  worse  at  night  than  in  the  day.  If  the  child  is  old 
enough  he  complains  of  a  harassing  tickling  in  the  throat ;  and  there  is 
often  violent  sneezing,  with  the  ejection  of  much  ropy  mucus  from  the 
nose. 

After  a  time  a  change  in  the  character  of  the  cough  shows  that  the 
spasmodic  stage  has  begun.  The  cough  occurs  in  paroxysms,  and  has 
such  a  distinctive  character  that  it  at  once  betrays  the  natui-e  of  the  child's 
complaint.  It  consists  in  a  number  of  short  hacks,  following  so  rapidly 
upon  one  another  as  to  allow  of  no  inspii-atory  effort.  As  these  continue, 
the  child's  face  turns  fi'om  red  to  pui-ple,  and  seems  to  swell  and  darken 
at  the  same  time.  At  length,  when  the  lungs  are  almost  exhausted  of 
their  air,  and  the  patient  seems  upon  the  Yerj  point  of  suffocation,  air  is 
at  last  drawn  in  with  a  long,  deejD  inspiration,  accompanied  by  the  charac- 
teristic "  kink  "  or  whoop.  Immediately,  however,  the  cough  begins  again  ; 
and  in  this  way  the  long  rapid  expiratory  cough,  the  signs  of  imminent 
asphyxia,  and  the  slower  whooping  inspiration  may  be  rejDeated  several 
times  before  the  expulsion  of  a  large  quantity  of  thick  tenacious  phlegm 
from  the  mouth,  and  perhaps  the  ejection  of  food  mixed  -with  ropy  mucus 
from  the  stomach,  announces  the  end  of  the  attack.  The  child,  then,  if 
an  infant,  sinks  back  exhausted  and  perspiring  in  his  mother's  arms,  and 
if  the  cough  do  not  return  immediately,  usually  falls  into  a  hea^y  sleep. 
An  older  child  seems  a  little  langTiid,  but  if  the  paroxysm  has  not  been 
severe,  may  return  quickly  to  his  amusement.  If,  on  the  contrarj^,  the 
spasm  has  been  prolonged,  he  may  seem  dull  and  confused  for  a  time,  and 
may  complain  of  headache. 

During  the  fits  of  coughing  the  pulse  becomes  very  rapid,  and  is  almost 
uncountable.  If  we  hsten  to  the  back  at  this  time  we  hear  some  slight 
wheezing  in  the  large  air-tubes  during  the  expii-atory  cough  ;  but  during 
the  long-drawn  insjDiration  an}'-  sUght  vesicular  sound  which  might  be 
heard  is  covered  by  the  noise  of  the  whoop.  In  the  intervals  of  the  cough 
auscultation  in  an  uncomphcated  case  merely  reveals  a  few  large  bubbles 
mixed  up  with  dry  wheezing  sounds  scattered  about  the  lungs. 

When  the  paroxysms  are  violent  they  are  a  cause  of  great  distress  to 
the  patient.  This  is  weU  shown  by  the  efforts  a  young  child  will  make  to 
keep  them  back.  He  may  be  noticed,  while  on  his  mother's  lap,  to  hold  his 
breath  and  sit  perfectly  still  in  the  hope  of  repressing  the  cough.  AATien 
he  feels  that  the  impulse  is  getting  beyond  his  control  his  face  becomes 
congested,  his  brows  contract,  and  sweat  breaks  out  on  his  forehead  ;  and 
as  the  con-vailsive  expiratory  efforts  begin,  he  clutches  at  his  mother's  dress 
and  often  trembles  all  over  with  nervous  agitation.  During  the  paroxysm 
the  straining  may  produce  ruptm-e  in  a  child  predisposed  to  hernia  ;  and 
haemorrhage  fi'om  the  intense  congestion  induced  is  a  common  symjotom. 
The  bleeding  may  take  place  from  the  eyes,  the  ears,  the  nose,  the  mouth, 
and  sometimes  from  the  lungs.  Cracks  about  the  lijDS  and  sore  plaices  on 
the  gums  almost  always  bleed  during  the  fits  of  coughing.     Epistaxis  is 


WHOOPING-COUGH — SYMPTOMS — COMPLICATIONS.  117 

■veiy  common.  "WThen  hsemorrliage  occurs  from  the  nose  the  blood  does 
not  always  flow  forwards  through  the  nostrils  ;  often  it  passes  backwards 
through  the  posterior  nares  into  the  throat.  It  may  be  then  swallowed 
and  discharged  as  black  matter  by  stool,  or  be  vomited  after  the  next  at- 
tack of  cough  and  cause  great  alarm.  In  other  cases  the  blood  irritates 
the  glottis  and  induces  a  fresh  paroxysm.  It  is  then  expelled  with  the 
cough  and  is  supposed  to  come  from  the  lungs. 

The  number  of  paroxysms  that  occur  in  the  twenty-four  hours  varies 
very  much  according  to  the  severity  of  the  attack,  and  partly,  too,  accord- 
ing to  the  number  of  disturbing  causes  to  which  the  child  is  exposed.  In 
severe  cases,  where  the  sHghtest  emotional  or  other  influence  will  induce 
an  attack,  the  number  may  be  considerably  diminished  by  quiet  and  judi- 
cious amusement.  The  child  often  coughs  more  in  the  night  than  duiing 
the  day,  for  the  occurrence  of  the  seizures  appears  to  be  favoui'ed  by  the 
recmnbent  position.  Between  the  paroxysms,  when  the  spasm  is  violent, 
the  child's  face  may  remain  permanently  congested.  The  eyes  are  red 
and  often  bloodshot ;  the  eyelids  are  heavy  and  swollen  ;  the  face  and  lips 
are  dull  red  ;  there  is  a  dusky  tint  round  the  mouth  and  under  the  eyes, 
and  the  veins  of  the  neck  are  full. 

The  attacks  themselves  vary  in  character.  "  The  whoop  may  be  entu'ely 
absent  throughout  the  disease.  This  is  said  to  be  common  in  very  young 
infants.  The  number  of  expiratory  efforts  is  very  variable.  Usually  there 
are  only  two  or  three,  but  they  maybe  much  more  numerous.  As  a  rule 
the  coughing  fits  are  longer  at  the  beginning  of  the  spasmodic  stage,  when 
secretion  is  thinner  and  less  copious,  than  at  a  later  period,  when  it  becomes 
abundant  and  more  tenacious.  After  the  whoop  has  lasted  a  fortnight  it 
grows  less  violent  and  is  less  fi-equently  heard.  It  only  occurs  with  the 
more  violent  fits  of  coughing,  and  in  the  milder  ones  the  breath  is  drawn 
more  quietly  and  with  greater  ease.  At  the  end  of  three  weeks  or  a  month 
it  becomes  very  rare,  and  the  complaint  may  then  be  said  to  have  passed 
into  the  stage  of  decline. 

The  whole  time  occupied  by  an  attack  of  whooping-cough  varies  from 
a  fortnight  or  even  less  to  two  months  or  longer.  The  duration  is  often 
difficult  to  ascertain,  for  after  the  spasmodic  cough  has  disappeared  and 
the  disease  has  again  come  to  assume  an  ordinary  catarrhal  type,  trifling 
accidents,  such  as  a  chill  or  an  error  in  diet,  may  set  up  more  active  symp- 
toms, and  the  whoop  may  even  return  for  a  time.  In  this  way  the  com- 
plaint may  be  prolonged  for  many  weeks. 

Complications. — There  are  certain  accidents  attendant  upon  the  com- 
plaint which  may  be  a  cause  of  distress  or  danger  to  the  patient.  Sub- 
lingual ulceration  is  common  ;  hsemorrhage  may  be  copious  ;  the  vomiting 
may  greatly  interfere  with  nutrition  ;  bowel  complaints  may  supervene  ; 
the  nervous  symptoms  may  be  exaggerated  ;  and  various  pulmonary  dis- 
eases may  ensue  and,  if  they  do  not  prove  fatal,  injuriously  affect  the  future 
welfare  of  the  child. 

The  sublingual  ulceration  has  been  before  referred  to.  It  occupies  the 
frsenum  of  the  tongue  and  may  extend  for  some  distance  on  each  side  of 
the  middle  line.  The  sore  may  vary  from  a  mere  abrasion  to  a  deep  fis- 
sui-e  with  a  gray  or  yellowish  surface.  It  is  only  seen  in  cases  where  the 
child  has  cut  the  lower  incisors,  and  is  the  direct  consequence  of  the  scrap- 
ing of  these  teeth  against  the  under  surface  of  the  tongue  as  this  organ  is 
protruded  and  withdrawn  during  the  paroxysms  of  cough.  Blood  often 
exudes  from  the  abraided  surface  towards  the  end  of  a  paroxysm.  The 
ulcer  is  not  a  constant  symptom.     It  never  appears  before  the  spasmodic 


118  DISEASE  IlSr   CHILDEEN. 

stage,  but  may  then  be  seen  as  early  as  the  fourth  day  of  the  whoop.  It 
is  most  common  in  infants  who  have  cut  the  two  central  lower  incisors  and 
no  other  teeth.  In  children  who  have  cut  all  their  teeth  the  symptom  is 
much  less  common. 

Hasmorrhage  must  not  be  looked  upon  as  in  every  case  an  untoward 
accident.  When  the  spasm  is  violent  and  the  congestion  of  the  head  and 
face  extreme,  the  relief  afforded  by  a  discharge  of  blood  from  the  distended 
vessels  of  the  nose  is  no  doubt  often  a  salutary  incident.  If,  however,  the 
haemorrhage  occur  frequently  and  be  very  coj)ious,  great  weakness  may  be 
occasioned  ;  and  if  the  child  be  already  reduced  by  the  violence  of  the  at- 
tacks and  the  deficiency  of  nourishment  occasioned  by  repeated  vomiting, 
the  loss  of  blood  may  be  an  additional  reason  for  anxiety.  Rupture  of 
vessels  elsewhere  than  in  the  nose  seldom  occurs  to  any  extent.  Blood 
ejected  from  the  mouth  during  whooping-cough  comes  almost  invariably 
from  this  source.  Haemoptysis  is  rarely  seen,  for  blood  coming  up  from 
the  lungs  after  an  attack  is  usually  swallowed  by  children,  and  is  seldom, 
if  ever,  sufficiently  considerable  to  be  a  source  of  danger. 

Haemorrhage  may  also  occur  into  the  subcutaneous  connective  tissue  of 
the  eyelids  and  that  beneath  the  conjunctiva.  The  eyes  are  often  blood- 
shot from  small  ecchymoses,  and  occasionally  we  see  little  extravasations 
in  the  thickened  eyelids. 

Haemorrhage  from  the  ears  is  the  consequence  of  ruptiu-e  of  the  tym- 
panic membrane.  Several  instances  of  this  accident  have  been  recorded. 
It  is  occasioned  by  the  blast  of  air  which  is  forced  through  the  Eustachian 
tube  during  the  fits  of  coughing,  and  a  certain  amount  of  blood  exudes 
from  the  torn  surface.  In  two  out  of  four  cases  published  by  Dr.  Gibb 
the  rupture  occurred  in  both  ears. 

In  very  rare  cases  hsemorrhage  has  been  noticed  in  the  brain  and  its 
membranes,  causing  death. 

Certain  digestive  troubles  may  arise.  Vomiting  at  the  end  of  a  fit  of 
coughing  is  a  familiar  symptom.  Usually  it  is  of  little  consequence.  If, 
however,  the  attacks  of  cough  occur  very  frequently,  and  are  followed  in 
each  case  by  sickness,  the  child's  nutrition  is  visibly  affected  ;  for  almost 
all  the  food  taken  is  vomited  before  there  is  time  for  digestion  to  begin. 
Even  if  vomiting  is  not  excessive,  there  is  often  considerable  interference 
with  nutrition,  for  the  catan-hal  condition  of  the  gastric  mucous  membrane 
is  ill  adapted  to  further  healthy  digestion.  In  many  cases,  no  doubt,  the 
tough  mucus  which  coats  the  wall  of  the  stomach  prevents  the  food  from 
being  properly  mingled  with  the  digestive  juices.  It  is  not  uncommon,  as 
M.  Rilliet  long  ago  pointed  out,  for  food  to  be  vomited  little  changed  sev- 
eral hours  after  a  meal.  On  account  of  the  mucous  flux  in  the  bovi-els 
worms  are  a  frequent  complication,  and  diarrhoea  is  easily  excited.  A  cer- 
tain amount  of  looseness  of  the  bowels  is  present  in  a  large  majority  of  the 
cases  of  pertussis,  and  considerable  quantities  of  mucus  are  passed  in  the 
stools. 

Nervous  accidents  form  a  very  important  class  of  complications.  Some- 
times the  laryngeal  spasm  is  exaggerated.  It  is  not  uncommon  to  see  a 
child  at  the  end  of  the  long  exph-atory  cough,  instead  of  at  once  beginning 
to  whoop,  remain  for  some  seconds  with  darkened  face,  staring  eyes,  and 
open  mouth,  making  agitated  movements  and  vainly  striving  to  overcome 
the  spasmodic  contraction  which  is  closing  the  entrance  to  his  lungs.  If 
prolonged  the  spasm  adds  greatly  to  the  gravity  of  the  case,  and  may  even 
determine  the  fatal  issue.  This  is  especially  likely  to  happen  if  the  per- 
tussis is  complicated  with  serious  lung  mischief.     In  a  case  which  came 


WHOOPING-COUGH — COMPLICATIOI^rS.  119 

under  my  own  notice — a  child  of  seven  years  of  age,  both  of  whose  lungs 
were  the  seat  of  catarrhal  pneumonia — the  spasms  were  "very  violent  and 
prolonged,  and  in  one  of  them  the  patient  died.  In  a  case  recorded  by 
Drs.  Meigs  and  Pepper,  whooping-cough  complicated  a  case  of  laryngismus 
stridulus,  and  the  child  died  in  a  spasm.  Sometimes  the  patient  falls  into 
a  state  of  syncope  from  which  he  can  be  roused  only  with  the  gTeatest 
difficulty. 

The  semi-asphyxiated  state  in  which  the  patient  is  often  left  after  a 
severe  paroxysm  of  cough  may  be  a  cause  of  general  convulsions.  Eclamp- 
tic attacks,  indeed,  often  complicate  pertussis ;  but  although  their  occur- 
rence should  give  rise  to  great  anxiety,  the  seizures  are  not  necessarily 
fatal.  If  the  convulsion  be  the  consequence  merely  of  deficient  aeration  of 
the  blood,  the  return  of  free  respiration  removes  the  danger  for  a  time  ; 
but  if  the  same  condition  be  frequently  renewed,  the  child's  state  is  a  very 
anxious  one.  So,  also,  convulsions  excited  by  embolisms  or  congestions  of 
the  cerebral  vessels,  thrombosis  of  the  cranial  sinuses,  or  diffused  collapse 
of  the  lungs,  are  very  serious.  These  generally  occin-  late  in  the  disease 
and  are  almost  invariably  fatal.  There  are  two  forms  of  eclampsia  liable  to 
happen  which  are  less  dangerous.  One  of  these  is  due  to  an  exaggeration 
of  the  nervous  excitement  which  is  an  ordinary  symptom  of  the  disease. 
In  highly  sensitive  children  it  is  probably  not  uncommon  for  convulsions 
to  take  place  from  this  cause,  especially  if  the  strength  has  been  quickly 
reduced  by  copious  epistaxis.  So,  also,  the  onset  of  an  inflammatory  com- 
plication is  often  indicated  by  a  convulsive  fit,  and  these  attacks,  like  the 
preceding,  are  often  recovered  from.  If,  however,  a  convulsive  fit  occur 
late  in  the  disease,  when  there  is  much  consolidation  of  lung,  the  child 
seldom  recovers.  In  connection  with  this  subject  it  is  well  to  remember 
that  convulsions  occurring  in  the  course  of  whooping-cough  may  be  due 
only  indirectly  to  that  disease.  The  tendency  to  eclamptic  attacks  which 
is  common  in  early  life  is,  no  doubt,  heightened  by  the  state  of  ner- 
vous excitement  in  which  the  System  is  maintained  by  the  illness.  At  any 
rate  it  is  common,  especially  in  rickety  childreu,  to  find  convulsions  su- 
pervene in  the  course  of  whooping-cough  upon  very  sHght  gastric  or  in- 
testinal irritation.  Convulsions  occurring  in  pertussis  without  being 
followed  by  ill  consequences  may  be,  no  doubt,  often  attributed  to  this 
cause. 

Another  important  group  of  complications  consists  of  the  pulmonary 
lesions  which  may  occur  in  the  course  of  whooping-cough.  These,  on  ac- 
count of  the  nature  of  the  complaint  and  the  tender  age  of  the  patient,  are 
readily  excited,  and  often  bring  the  illness  rapidly  to  a  close.  In  fact,  the 
liability  to  these  accidents  constitutes  in  most  cases  the  chief  danger  of  the 
disease. 

Collapse  of  the  lung  is  one  of  the  commonest  and  most  fatal  of  these 
complications.  In  a  severe  case  of  whooping-cough  in  a  young  child  this 
accident  may  happen  at  any  time.  Indeed,  it  may  be  said  that  at  the  end 
of  every  violent  paroxysm  of  coughing  the  patient  is  threatened  with  col- 
lapse of  the  lung,  for  all  the  conditions  which  conduce  to  this  disaster  are 
present  together.  Thus  the  spasmodic  cough  almost  empties  the  lungs  of 
air ;  the  ropy  mucus  in  the  tubes  offers  an  obstacle  to  its  re-entrance  ;  and 
the  state  of  exhaustion  in  which  the  patient  is  left  weakens  the  force  of  the 
inspiratory  act.  The  mechanism  of  collapse  of  the  lung  and  the  symptoms 
and  signs  which  result  from  it  are  described  at  length  in  another  place. 
It  will  be  sufficient  here  to  remark  that  the  occurrence  of  coUapse  is  often 
indicated  by  an  attack  of  convulsions,  and  if  the  area  of  lung  affected  be 


12  )  DISEASE   IN    CHILDEEN. 

large,  sudden  death  may  even  ensue.  In  the  less  serious  cases  the  child  lies 
back  with  his  head  low  ;  his  face  is  pale  or  slightly  livid  and  covered  with 
a  cold  sweat ;  the  eyelids  and  lips  are  dull  red  or  purple  ;  the  nares  act, 
and  the  respirations  are  frequent  and  shallow.  There  is  no  fever  ;  often 
the  temperature  is  lower  than  natural.  On  examination  of  the  chest  we 
find  a  little  dulness  at  one  or  both  bases  behind  ;  the  breathing  is  bron- 
chial, and  sometimes  loose  crackling  rhonchus  may  be  heard  at  the  lower 
part  of  each  lung.  The  whoop  generally  ceases  when  collapse  occurs,  but 
the  fits  of  coughing  continue,  although  in  a  modified  form,  and  add  greatly  to 
the  exhaustion  of  the  patient.  These  cases  almost  invariably  end  in  death. 
The  child  lies  qtiietly,  as  if  unwilling  to  stir  a  muscle.  He  takes  food  with 
difficulty  and  seems  afraid  to  swallow.  If  lifted  up  suddenly  he  may  die 
from  syncope  :  often  the  end  is  preceded  by  a  convulsion. 

Bronchitis  and  catarrhal  pneumonia  are  other  common  consequences  of 
whooping-cough.  The  pulmonary  catarrh,  which  is  one  of  the  characteristic 
features  of  the  disease,  is  easily  aggravated,  and  readily  invades  the  smaller 
tubes  of  the  lung.  In  a  young  child,  too,  a  bronchitis  seldom  remains  a 
bronchitis,  but  the  inflammation  quickly  travels  to  the  fine  bronchioles  and 
air -vesicles.  Thus  a  catarrhal  pneumonia  is  easily  set  up.  In  a  severe 
case  of  pertussis  the  breathing  becomes  more  and  more  oppressed  and  the 
face  more  and  more  livid  as  the  catarrhal  inflammation  extends  itself ;  but 
when  the  terminal  tubes  are  reached  and  catarrhal  pneumonia  begins,  the 
change  is  at  once  announced  by  new  symptoms.  The  whoop  ceases ;  the 
temperature  rises  to  102°  or  103''  ;  the  breathing  is  quickened  and  laboured, 
and  the  pulse-respiration  ratio  is  perverted ;  the  face  is  livid ;  the  nares  are 
widely  expanded.  Although  there  may  be  no  percussion  dulness,  a  physical 
examination  of  the  chest  reveals  some  of  the  signs  connected  with  this  dan- 
gerous condition.  Soujetimes  a  fit  of  convulsions  ushers  in  the  complication. 
If  the  pneumonia  be  extensive  the  child  generally  dies.  If  it  be  moderate, 
and  the  attack  of  whooping-cough  be  nearing  its  close,  he  may  recover, 
but  his  life  may  be  said  to  hang  on  a  thread,  for  the  occurrence  of  a  little 
collapse,  still  further  reducing  the  amount  of  breathing  space  left  to  him, 
may  at  once  determine  the  fatal  issue. 

Emphysema  of  the  lung,  which  often  occurs,  is  a  complication  of  little 
gravity.  It  usually  occupies  the  upper  lobes  and  anterior  borders  of  the 
lungs.  It  is  produced  mechanically  by  forcible  distention  of  the  air-vesi- 
cles, air  being  driven  from  the  lower  parts  of  the  lungs  into  the  upper  por- 
tions during  the  spasmodic  cough,  or  rather  during  the  violent  contrac- 
tions of  the  diaphragm  which  immediately  precede  the  cough  when  the 
glottis  is  closed.  In  the  severer  cases  there  is  some  dilatation  of  the 
smaller  bronchi  as  well  as  of  the  air-cells.  The  condition  is  an  acute  one, 
and  usually  subsides  when  the  disease  passes  off.  In  scrofulous  children, 
however,  it  may  remain  as  a  permanent  lesion. 

Of  these  complications  emphysema  is  one  of  early  occurrence.  Col- 
lapse and  catarrhal  pneumonia  occur  late  in  the  disease,  as  a  rule,  when 
the  child's  strength  is  reduced  and  his  nutrition  impaired. 

Besides  the  above  accidents  others  may  occur.  Laryngitis  is  seen 
sometimes,  but  if  not  severe  adds  little  or  nothing  to  the  danger  of  the 
case.  Pleurisy  and  pericarditis  are  occasionally  found,  but  these  do  not, 
like  the  preceding,  follow  naturally  from  the  complaint,  and  are  not  often 
met  with. 

Sequelae. — When  the  disease  has  passed  off  consequences,  local  and 
constitutional,  may  be  left  behind.  Any  diathetic  taint,  previously  dor- 
mant, is-ofteu  roused  into  activity.    Scrofulous  children  may  become  subject 


WHOOPIl^G-COUGII— SEQUELiE.  121 

to  chronic  discharges,  inflammations,  and  other  signs  of  that  constitutional 
•condition  ;  sj-philis  in  babies  may  first  manifest  itseH  during  or  after  an 
attack  of  whooping-cough  ;  and  acute  tuberculosis  is  a  not  unfrequent 
sequel  to  the  disease.  Measles  and  pertussis  seem  to  have  a  certain 
affinity  in  that  they  both  produce  an  especially  injurious  effect  upon 
■scrofulous  children.  In  such  subjects  chronic  caseous  enlargements  of 
the  cervical  and  bronchial  glands  are  common  :  catarrhal  inflammation  of 
the  lungs  tends  to  pass  into  a  chronic  stage  and  produce  serious  mischief, 
and  chronic  bronchitis  vpith  emphysema  may  make  the  child  a  permanent 
invalid.  Acute  tuberculosis,  v^dien  not  the  consequence  of  hereditary 
diathetic  tendency  excited  by  the  occurrence  of  whooping-cough,  may 
be  set  up  as  a  result  of  softening  of  caseous  bronchial  glands,  and  this 
.at  a  considerable  interval  of  time  after  the  primary  disease  has  come  to 
an  end. 

Besides  these  constitutional  conditions  there  are  other  local  conse- 
quences of  whooping-cough  which  it  is  important  to  be  aware  of. 

Laryngismus  stridulus  is  sometimes  a  relic  of  the  disease,  the  spasm 
persisting  although  the  other  symptoms  have  ceased.  This  is  not  com- 
mon, and  probably  only  occurs  in  the  subjects  of  rickets. 

Children  who  have  lately  passed  through  an  attack  of  whooping-cough 
are  often  slow  to  recover  their  strength  and  healthy  appearance,  even 
although  they  are  innocent  of  any  diathetic  taint,  and  have  no  chest  af- 
fection to  set  up  pyrexia  and  be  a  cause  of  weakness.  A  group  of  symp- 
toms is  often  noticed  in  such  subjects  which  I  have  elsewhere  described 
under  the  name  of  "  mucous  disease," '  and  which  indicates  a  marked 
degree  of  impairment  of  nutrition.  The  child  is  languid  and  pale,  or  has 
a  dingy  sallow  complexion  ;  he  loses  flesh,  is  easily  tired,  and  sleeps  badly 
at  night.  There  is  often  some  discolouration  under  the  eyes,  and  the 
complexion  may  turn  suddenly  ghastly  white,  as  if  the  child  were  going  to 
faint.  Often  he  does  faint ;  and  he  frequently  complains  of  a  stitch  in  the 
side  and  is  subject  to  flatulent  pains  about  the  belly.  The  tongue  pre- 
sents a  peculiar  appearance.  It  has  a  glossy  slimy  look,  is  often  coated 
with  a  thin  gray  fur,  and  the  large  papillse  at  the  sides,  although  not 
prominent,  are  unusually  distinct.  A  curious  irritability  is  a  characteristic 
feature  of  the  disorder.  The  child  is  capricious  and  fretful,  and  often 
cries  without  cause.  He  quarrels  needlessly  with  his  brothers  and  sisters, 
and  is  sometimes  quite  a  torment  in  the  nursery.  At  night  he  dreams  and 
(Often  wakes  up  in  violent  panic.  The  "  night  terrors  "  of  children  usu- 
.ally  occur  in  the  subjects  of  this  derangement,  and  sometimes  the  child 
gets  out  of  bed  and  wanders  about  in  his  sleep.  These  symptoms  have  no 
Tegular  progression.  They  are  better  and  worse.  Sometimes  the  child 
seems  almost  well  ;  then,  in  a  day  or  two,  he  is  as  bad  as  ever.  The 
patients  are  subject  to  what  are  called  "bilious  attacks."  They  are  seized 
suddenly  with  vomiting  and  purging,  which  lasts  for  twenty-four  hours  or 
a  day  or  two,  and  at  these  times  get  rid  of  large  quantities  of  thick  mucus 
both  from  the  stomach  and  bowels.  After  this  relief  they  seem  better  for 
a  time.  They  are  less  irritable  and  languid,  their  temper  improves,  and 
their  rest  at  night  is  no  longer  disturbed.  After  a  few  days,  however,  the 
.symptoms  return,  and  continue  until  they  are  again  relieved  in  the  same 
way.  As  a  rule,  the  bowels  are  rather  costive,  and  an  aperient  always 
iDrings  away  much  mucus  with  the  stools. 

These  symptoms  are  due  to  a  continuance  of  the  mucous  flux  from  the 

'  See  The  Wasting  Diseases  of  Children,  4th  ed. 


122  DISEASE   IlSr   CHILDEElSr. 

alimentaiy  canal  whicli  is  always  present  to  a  greater  or  less  degree  in 
cases  of  pertussis.  This  copious  alkaline  secretion  acts  as  a  fennent  and 
causes  an  acid  change  in  the  more  fermentable  articles  of  food.  The  acid 
thus  generated  partially  coagulates  the  mucus,  so  that  this  forms  a  thick 
coating  round  the  interior  of  the  digestive  tube,  and  also  covers  the 
masses  of  food  swallowed.  Consequently  a  proper  admixture  of  food  with 
the  gastric  juices  and  other  digestive  fluids  is  interfered  with,  digestion  is 
slow  and  imperfect,  and  of  the  food  which  is  digested  only  a  small  part  is 
brought  into  contact  with  the  absorbent  vessels.  The  child  consequently 
gets  thinner  and  paler.  He  is  uneasy  on  accouxLt  of  flatulent  pains  from 
gases  disengaged  in  the  process  of  fermentation,  and  in-itable  on  account 
of  the  excess  of  acid  vrith  which  the  system  is  charged.  In  bad  cases  the 
emaciation  may  be  very  great,  and  although  the  appetite  may  be  large, 
the  food  taken  seems  to  be,  and  often  actually  is,  neai-ly  useless  for  23ni-- 
poses  of  nutrition.  Commonly,  however,  when  the  derangement  is  severe 
the  appetite  fails,  and  great  difficulty  is  found  in  persuading  the  child  to 
take  any  nourishment  at  all.  Parasitic  woitqs,  which  find  in  the  alkahne 
mucus  a  congenial  nidus  for  develojDment,  frequently  complicate  this  de- 
rangement, but  it  is  to  the  digestive  disorder  and  not  to  the  worms  that  the 
symptoms  are  really  due. 

Diagnosis. — It  is  often  very  difficult  to  say  whether  or  not  a  child  has 
got  whooj)ing-cough.  At  the  beginning  of  the  catarrhal  stage  a  diagnosis 
is  impossible.  At  this  early  period  we  can  only  detect  the  signs  of  catarrh, 
and  unless  the  complaint  is  largely  prevalent  at  the  time,  or  other  childi'en 
in  the  house  are  suffering  from  pertussis,  there  is  absolutely  nothing  to 
make  us  even  suspect  its  existence.  Often,  towards  the  end  of  this  stage, 
the  fi'equency  and  peculiar  violence  of  the  fits  of  coughing  may  rouse  our 
suspicions,  and  if  a  genuine  paroxysm  occur*,  doubt,  of  course,  ceases  to 
be  possible.  But  although  fully  developed  whooping-cough  cannot  be  mis- 
taken, the  modified  form  of  cough  which  is  often  all  that  we  can  detect 
may  be  easily  misinteipreted.  A  more  or  less  prolonged  cough  with  a 
faint  whoop  from  shght  laryngeal  spasm  is  not  very  uncommon  in  a  child 
suffering  from  chest  complaint,  and  an  abortive  pertussis  may  sometimes 
give  rise  to  no  more  characteristic  symptoms  than  these.  In  making  the 
distinction  no  arguments  drawn  from  the  acuteness  of  the  attack  or  the 
early  period  at  which  the  cough  assumed  the  spasmodic  character  can  be 
relied  ujDon,  for  modified  pertussis  may  be  as  shght  and  transient  as  any 
mere  pulmonary  catarrh.  It  is  of  far  gi-eater  importance  to  notice  that  in 
a  mild  form  of  whooping-cough  the  general  health  is  good,  and  that  an 
examination  of  the  chest  reveals  little  deviation  fi'om  the  normal  state  of 
things  ;  while  a  chest  affection  sufficiently  serious  to  produce  an  imitation 
of  whooping-cough  will  injure  the  general  health  and  modify  the  i^hysical 
signs.  It  is  usually  in  cataiThal  pneumonia  that  this  riolent  jDrolonged 
cough  is  noticed.  In  such  cases  we  find  the  symptoms  and  physical  sig-ns 
of  this  disease,  and  we  exclude  pertussis  by  remarking  that  the  cough  did 
not  become  paroxysmal  until  the  chest  disease  was  well  developed.  In  a 
case  of  real  pertussis  with  secondary  cataiThal  pneumonia,  the  character- 
istic cough  is  very  much  modified  immediately  the  complication  begins. 
Paroxysms  of  violent  cough  with  some  spasm  of  the  larynx  are  often  no- 
ticed in  cases  of  enlargement  of  the  bronchial  glands.  But  here  we  get 
other  signs  of  pressure  upon  the  pneumogastric  neiwe  :  the  breathing  is 
more  or  less  oppressed  and  the  voice  is  thick  and  hoarse  between  the 
attacks  of  cough.  Besides,  the  venous  radicles  of  the  face,  neck,  and  chest 
are  usually  more  visible  than  natural  from  pressure  upon  the  innominate 


WHOOPING-COUGH — DIAGJNTOSIS — PROGNOSIS.  123 

vein  ;  there  is  no  expectoration  of  ropy  mucus  ;  and  the  disease  is  not 
capable  of  being  communicated  to  other  children. 

When  convulsions  occur  in  a  case  of  whooping-cough  it  is  very  impor- 
tant, with  a  view  to  prognosis,  to  ascertain  their  mode  of  origin.  If  the 
convulsion  is  symptomatic  of  the  onset  of  an  inflammatory  complication,  it 
is  accompanied  by  a  rise  of  temperature  and  followed  by  a  diminution  in 
the  spasmodic  symptoms  and  a  modification  of  the  physical  signs  in  the 
chest.  If  it  announces  the  occurrence  of  collapse  of  the  lung,  the  charac- 
teristic symptoms  which  mark  that  lesion  will  be  present. 

If  the  convulsion  arises  from  exaggeration  of  the  nervous  disturbance 
which  is  one  of  the  pecuhaiities  of  the  disease,  it  will  have  been  preceded 
by  signs  of  unusual  agitation  in  former  fits  of  coughing.  Such  seizures  are 
only  seen  in  children  known  to  be  nervous,  sensitive,  and  impressionable  ; 
they  follow  immediately  upon  the  cough,  and  between  the  attacks  no 
signs  of  nervous  disturbance  remain.  So  also  in  the  case  of  convulsions, 
arising  from  partial  asj^hyxia  :  the  nervous  attack  is  excited  by  extreme 
violence  of  spasm,  but  after  the  fit  has  passed  off  no  signs  of  cerebral 
lesion  are  left  behind.  If,  after  a  fit,  there  is  squinting,  drowsiness, 
stupor,  or  other  sign  of  nervous  disturbance,  we  may  fear  that  congestion 
of  brain  is  present  or  that  thrombosis  of  the  cerebral  sinuses  has  occurred, 
and  should  watch  the  case  with  grave  apj)rehension. 

Prognosis. — Whatever  be  the  age  of  the  child,  the  prognosis  is  favour- 
able so  long  as  the  disease  remains  uncomplicated  ;  but  if  a  complication 
arise  the  prospect  is  less  hopeful,  and  in  a  very  young  child  any  addition 
to  the  normal  course  of  the  complaint  is  to  be  regarded  with  anxiety. 
Con^Tilsions,  bronchitis  with  collapse,  and  catarrhal  pneumonia  are  the 
principal  causes  of  an  unfavourable  issue  to  the  disease. 

In  the  case  of  convulsions,  if  the  attack  can  be  connected  with  nervous 
agitation  or  the  onset  of  an  inflammatory  complication,  or  if,  after  the  fit, 
the  child  seem  bright  and  well,  there  is  still  room  for  favourable  anticipa- 
tion. If,  however,  the  seizure  is  symjDtomatic  of  diffused  pulmonary  col- 
lapse ;  if  it  occur  in  the  course  of  an  extensive  pulmonary  inflammation  ; 
or  if  it  be  followed  by  drowsiness,  squinting,  or  sign  of  cerebral  lesion, 
there  is  little  prospect  of  the  child's  recovery.  Sometimes  we  can  antici- 
pate the  occurrence  of  con"VTilsions.  If  we  find  the  child  to  be  nervous  and 
impressionable,  and  we  notice  that  he  displays  unusual  agitation  and  ex- 
citement on  the  approach  of  the  paroxysm,  we  may  be  prepared  for  an 
attack.  So  also  if  we  find  that  the  face  becomes  very  blue  during  the 
cough,  and  that  the  spasm  of  the  larynx  is  unusually  prolonged,  we  may 
fear  that  an  eclamptic  attack  may  ensue.  Larjmgismus  striduhis,  as  it 
supplies  an  additional  obstacle  to  the  aeration  of  the  blood  and  tends  to 
promote  collapse  of  the  lung,  is  an  unfavourable  sign.  If  it  occur  in 
combination  with  extensive  lung  mischief,  the  prospect  is  a  very  hojje- 
less  one. 

If  the  pulmonary  catarrh  becomes  aggravated,  the  presence  or  absence 
of  rickets  is  a  very  important  matter.  Softening  of  ribs  is  a  great  obstacle 
to  ef&cient  breathing  ;  and  if  the  presence  of  thick  mucus  in  the  tubes  pro- 
vides an  additional  impediment  to  the  entrance  of  air,  the  occurrence  of 
collapse  is  imminent.  If,  with  this,  the  spasms  are  violent,  and  the  child 
seem  much  exhausted  at  the  end  of  the  fit  of  coughiug,  collaj^se  of  the  lung 
may  be  considered  inevitable.  In  such  a  case  the  prognosis  is  a  very 
gloomy  one. 

If  the  catari'h  pass  to  the  small  air-tubes  and  vesicles,  and  set  up  catar- 
rhal pneumonia,  the  state  of  the  child  is  serious.     Still,  if  the  patient  be 


124  DISEASE   IE"   CHILDREN". 

of  healthy  constitiition  and  the  pertussis  of  comparatively  mild  type,  he 
has  a  chance  of  recovery.  In  a  rickety  child  the  prospect  is  very  bad.  In 
one  of  scrofulous  constitution,  if  he  cio  not  succumb  immediately,  there  is 
every  likelihood  that  a  chronic  consolidation  of  one  or  both  lungs  will  be 
left  behind. 

Treatment. — The  treatment  of  whooping-cough  resolves  itself  into  gen- 
eral measures  for  preventing  complications  and  furthering  the  normal 
working  of  the  animal  functions  ;  also,  in  special  treatment  for  shortening 
the  disease  and  diminishing  ^^.olence  of  spasm. 

If  possible,  the  child  should  be  confined  to  two  rooms  opening  into  one 
another,  so  that  he  may  inhabit  them  alternate^,  and  get  the  benefit  of  effi- 
cient ventilation.  Draughts  should  be  avoided,  and  the  temperature  be  kept 
as  nearly  as  possible  at  65°  Fahr.  If  the  rooms  have  no  door  of  communi- 
cation, the  child  should  be  taken  from  one  to  another,  wrapped  from  head  to 
foot  in  a  blanket.  Next,  quiet  and  the  avoidance  of  all  sources  of  excite- 
ment and  irritation  should  be  enforced.  If  old  enough  to  be  amused, 
quiet  games  and  picture-books  may  be  supplied  ;  and  a  teachable  child  is 
not  to  'be  worried  with  lessons  if  he  is  disinclined  for  them.  His  dress 
should  be  suitable  to  the  season,  but  bare  arms  and  legs  must  be  forbid- 
den, and  the  chest  should  be  covered  with  cotton- wadding  if  the  weather 
Ibe  changeable  or  cold. 

In  regulating  the  diet  care  should  be  taken  not  to  overload  the  stom- 
ach. Four  small  meals  are  better  than  three  large  ones,  and  attention 
must  be  paid  to  the  patient's  power  of  digesting  fermentable  articles  of 
food.  The  mucus  flux  from  the  stomach  and  bowels,  which  is  a  prominent 
feature  of  the  complaint,  is  an  active  agent  in  promoting  acidity ;  and 
starches  must  be  given,  therefore,  cautiously  and  in  limited  quantities.  A 
baby  does  well  upon  milk  and  barley-water  (equal  parts),  and  Mellin's 
food,  with  a  pinch  of  bicarbonate  of  soda  to  each  bottle.  He  may  also 
have  the  yolk  of  an  egg  twice  a  week,  and,  if  over  ten  months  old,  weak  veal 
or  chicken  broth  once  in  the  da}^  After  eighteen  months  the  child  may 
have  minced  meat,  or  fish,  milk,  eggs,  and  stale  bread,  but  potatoes  and 
farinaceous  puddings  are  to  be  avoided.  Well  boiled  cauliflower  or  greens 
may  be  given  if  the  patient  will  take  them. 

If  the  natural,  vomiting  does  not  sufficiently  unload  the  stomach  of  mu- 
cus, nature  ma}''  be  aided  by  the  occasional  administration  of  an  emetic. 
Sulphate  of  copper,  as  recommended  by  Trousseau,  is  very  useful  for  this 
purpose,  and  may  be  given  to  a  child  of  one  year  old  in  doses  of  half  a 
grain  every  ten  minutes  until  sickness  is  produced.  Also,  it  is  well  to  re- 
lieve the  bowels  by  an  occasional  dose  of  castor-oil.  Looseness  of  the  bow- 
els, such  as  is  common  in  this  complaint,  is  at  once  arrested  in  most  cases 
by  a  dose  of  this  useful  remedy. 

Of  special  drugs  for  shortening  the'attack  and  relieving  spasm,  so  many 
have  been  recommended  that  the  mere  enumeration  of  them  would  occupy 
many  Hnes  ;  but  of  really  serviceable  drugs  the  number  is  much  more  Hm- 
ited.  The  treatment  I  have  myself  found  to  be  most  useful,  and  now  inva- 
riably adopt,  is  the  following  : ' — Directly  any  peculiarity  in  the  cough  or 
the  occurrence  of  spasm  indicates  the  nature  of  the  complaint,  I  at  once 
begin  the  administration  of  sulphate  of  zinc  and  atropia.  From  a  large 
experience  of  this  combination  I  can  speak  positively  as  to  its  power  of 
reducing  spasm  and  shortening  the  disease.  I  begin  with  one-sixth  of  a 
grain  of  sulphate  of  zinc  and  half  a  drop  of  the  solution  of  atropine  (P.  B.) 

'The  quantities  recommended  are  suitable  to  a  child  twelve  months  of  age. 


WHOOPING-COUGH — TREATMENT.  125 

in  water  sweetened  with  glycerine,  each  morning  and  evening  for  two  days, 
and  then  three  times  a  day.  After  a  week  the  quantity  of  zinc  is  increased 
to  one-fourth,  and  still  later  to  one-third  of  a  grain.  The  atroj^ia,  how- 
ever, is  given  in  frequently  increasing  quantities.  Children,  although  they 
vary  in  their  insusceptibility  to  this  drug,  can  all  take  it  in  large  doses ; 
and  in  whooping-cough  where  there  is  spasm  to  be  overcome,  the  remedy 
is  of  little  value  unless  given  in  doses  sufficiently  large  to  produce  some  of 
the  physiological  efl'ects  of  the  alkaloid.  Excluding  the  belladonna  rash, 
which  is  too  uncertain  in  its  appearance  to  be  trusted,  dilatation  of  the 
pupil  is  the  earliest  symptom  that  the  system  is  responding  to  the  action 
of  the  medicine.  This  sign  is  separated  by  a  wide  interval  from  the  next 
earliest  symptom — dryness  of  the  throat.  To  be  of  service,  the  remedy 
should  be  pushed  so  as  to  produce  some  effect  upon  the  pupil.  With  this 
ob)ject  the  dose  should  be  increased  every  two  days  by  a  quarter  of  a  drop 
of  the  atropine  solution,  watching  the  effect.  In  this  way,  with  perfect 
safet}^,  large  quantities  of  the  drug  may  be  administered  ;  and  so  employed, 
I  think  no  doubt  can  be  entertained  as  to  the  value  of  the  treatment  and 
its  influence  in  shortening  the  course  of  the  spasmodic  stage  and  reducing 
the  violence  of  the  attacks.  If  the  spasm  is  exceptionally  severe  and  seems 
to  threaten  partial  asphyxia,  it  is  wise  to  give  in  addition  a  nightly  dose  of 
bromide  of  potassium  or  ammonium  (gr.  iij.-iv.).  There  is  one  precaution 
which  it  is  well  to  adopt  during  this  stage.  The  paroxysms  are  often  most 
frequent  and  severe  at  night  when  the  child  is  asleep.  The  shghtest  move- 
ment of  air  across  the  face,  such  as  is  produced  by  a  person  walking  near 
the  cot,  will  often  excite  an  attack.  These  night  seizures  can  usually  be 
greatly  reduced  in  number  by  an  expedient  suggested,  I  beheve,  originally 
by  Dr.  Marshall  Hall.  It  consists  in  throwing  a  fine  muslin  curtain  over 
the  cot  at  night-time.  The  simplest  plan  is  to  have  a  couple  of  hoops  ar- 
ranged at  the  ends  of  the  cot,  like  the  "tilts"  of  a  wagon,  so  as  to  support 
the  curtain  at  a  sufficient  height.  This  arrangement,  which  corresponds 
to  the  mosquito  curtain  used  in  hot  climates,  does  not  interfere  with  a 
free  supply  of  oxygen,  while  it  effectuall}^  stops  all  wandering  currents 
of  air.  So  protected,  a  child  will  often  sleep  the  night  through  without 
an  attack. 

At  the  end  of  the  spasmodic  stage  and  during  the  period  of  decline 
alum  is  very  beneficial.  This  remedy,  first  recommended  by  Dr.  Golding 
Bird  in  1845,  has  a  marked  influence  in  checking  too  copious  secretion  and 
bringing  the  disease  to  a  favourable  termination.  Two  or  three  grains  of 
alum  may  be  substituted  for  the  sulphate  of  zinc  in  the  atropia  mixture, 
and  given  three  times  in  the  day.  It  is  at  this  time,  viz.,  the  end  of  the 
spasmodic  stage  and  during  the  period  of  decline,  that  I  have  found  the 
quinine  treatment  especially  useful.  I  have  little  experience  of  the  drug 
at  the  beginning  of  an  attack.  According  to  Binz,  Jansen,  and  others, 
who,  following  the  suggestion  of  Letzerich,  direct  their  attacks  against  the 
organism  which  has  been  supposed  to  cause  whooping-cough,  quinine 
given  at  the  beginning  of  the  illness  suppresses  altogether  the  spasmodic 
element,  and  converts  the  disease  into  a  severe  but  manageable  bron- 
chitis. They  recommend  the  comparatively  tasteless  tannate  of  quinine, 
given  twice  a  day  in  doses  of  a  grain  and  a  half  for  every  year  of  the 
child's  life. 

There  is  no  doubt  that  to  be  efficient  in  pertussis  quinine  should  be 
given  in  full  doses.  I  have  given  three  times  a  day  two  grains  of  the  sulphate 
of  quinine  to  children  between  twelve  months  and  two  years  old  towards 
the  end  of  the  spasmodic  stage,  and  have  thought  that  the  disease  was  cut 


126  DISEASE   IN   CHILDREN. 

short  by  this  means.  Another  combination  which  acts  sometimes  at  this 
period  of  the  illness  with  wonderful  promptitude  is  formed  by  adding  two 
drops  of  the  tincture  of  cantharides  to  five  drops  each  of  the  tincture  of 
cinchona  and  paregoric,  and  giving  this  dose  three  times  a  day.  Tonics 
generally  are  useful  during  the  stage  of  decline.  The  preparations  of  iron 
are  especially  valuable.  Thirty  drops  each  of  the  compound  decoction  of 
aloes  and  iron  wine  make  a  good  combination  ;  iodide  of  iron  is  of  service, 
and  the  citrate  of  iron  with  an  alkali  may  be  resorted  to.  It  is  a  matter 
of  great  practical  importance  in  all  these  cases  to  avoid  the  use  of  sj'rups 
in  sweetening  tlie  mixture  for  the  infant's  palate.  Glycerine,  being  non- 
fermentable,  is  far  safer  ;  or  we  may  use  a  few  drops  of  chloric  ether  for 
this  purpose. 

Many  other  drugs  are  used  in  the  treatment  of  whooping-cough.  The 
old  treatment  by  dilute  hydrocyanic  acid  and  that  by  dilute  nitric  acid, 
each  of  which  has  had  its  day,  has  now,  probably,  fallen  into  complete  dis- 
use. Opium,  however,  in  some  form  has  not  been  completely  superseded 
by  belladonna.  The  preparations  of  morphia  are  still  relied  upon  by  some 
jDractitioners,  and  the  remedy  is  no  doubt  a  useful  one.  It  should  be 
given  in  sufficient  doses  to  produce  slight  drowsiness,  and  this  effect 
should  be  maintained  for  several  days.  For  a  child  of  twelve  months  a 
drop  of  the  morphia  solution  (P.  B.)  can  be  given  every  four  hours.  There 
is  no  doubt  that  the  spasm  can  be  reduced  by  this  means  ;  but  the  treat- 
ment is,  in  my  opinion,  inferior  to  that  by  atropine,  and  necessitates  very 
careful  watching  of  the  patient  lest  the  narcotic  effect  of  the  remedy  be 
carried  further  than  is  desired.  Chloral  may  be  also  employed  to  reduce 
spasm  in  doses  of  gr.  ij.  every  four  or  six  hours.  It  is  sometimes  used  in 
combination  with  bromide  of  potassium,  and  the  effect  of  both  drugs  ap- 
pears to  be  heightened  by  the  association.  Croton  chloral  is  a  remedy 
greatly  relied  upon  by  some  practitioners.  The  dose  is  one  grain  for  a 
child  of  twelve  months,  given  every  four,  six,  or  eight  hours  in  water 
sweetened  with  glycerine. 

Besides  the  above  methods  of  treatment  the  topical  action  of  drugs 
is  largely  used  in  the  management  of  whooping-cough.  It  is  now 
nearly  thirty  years  since  Dr.  Eben  Watson  advocated  swabbing  the 
larynx  with  a  solution  of  nitrate  of  silver,  twenty  grains  to  the  ounce. 
The  application  was  repeated  every  second  day,  and  the  spasm  is  said 
to  have  subsided  at  the  end  of  the  week.  This  heroic  remedy  is  not 
now  in  vogue.  Instead,  milder  applications  sprayed  into  the  throat  are 
made  use  of.  A  two  per  cent,  solution  of  salicylic  acid  used  regularly  in 
this  manner  is  said  to  diminish  rapidly  the  number  of  paroxysms.  Dr. 
E.  J.  Lee  is  a  warm  advocate  of  carbolic  acid  inhalations,  and  claims  for 
them  that  they  induce  a  daily  decrease  in  the  violence  of  the  cough,  and 
promote  the  disappearance  of  the  symptoms  within  a  pjeriod  varying  from 
a  fortnight  to  three  weeks.  Dr.  Lee  prefers  long-continued  inhalations  of 
a  diluted  vapour,  and  recommends  that  the  air  of  the  room  should  be  kept 
saturated  with  a  weak  solution  of  carbolic  acid.  As  this  acid  does  not 
evaporate  when  exposed  to  the  air,  special  means  have  to  be  used  for  con- 
verting it  into  vapour.  Dr.  Lee's  "  steam  draft  inhaler,"  which  moistens 
the  air  as  well  as  medicates  it,  is  a  useful  and  simple  apparatus.  A  solu- 
tion of  one  part  of  the  acid  to  thirty  of  water  is  to  be  used  for  vaporisa- 
tion, and  by  this  means  the  child  may  pass  a  large  part  of  his  time  in  air 
kept  saturated  with  a  dilute  medicated  vapour.  If  carbolic  acid  be  in- 
haled in  the  ordinary  way  from  a  mouth-piece,  the  solution  should  not  be 
stronger  than  one  part  in  eighty  parts  of  water. 


WHOOPING-COUGH — TREATMENT.  127 

External  applications  have  not  been  neglected  in  the  treatment  of 
■whooping-cough.  Many  patent  remedies,  such  as  Roche's  embrocation, 
which  is  composed  of  the  oils  of  cloves  and  amber  with  double  their  quan- 
tity of  olive-oil,  belong  to  this  class.  Stimulating  hniments  are  often  useful 
if  the  catarrh  of  the  chest  is  severe,  and  if  applied  along  the  sides  of  the 
neck,  and  to  the  spine  as  weU  as  to  the  chest,  may  help  to  reduce  the  spasm. 
Mustard  poultices  to  the  back  are  favourite  remedies  with  some  practi- 
tioners, and  it  is  said  that  if  applied  along  the  whole  length  of  the  spine  for 
six  or  eight  minutes  every  night  before  the  child  is  put  to  bed  a  speedy  im- 
provement is  noticed  in  the  symptoms. 

When  complications  arise  in  the  course  of  whooping-cough,  special 
measures  must  be  adopted  for  their  relief.  If  the  vomiting  of  food  become 
excessive,  so  as  to  interfere  seriously  with  the  child's  nutrition,  it  may  be 
often  relieved  by  emetics  of  sulphate  of  copper  (half  a  grain  to  the  tea- 
spoonful)  given  every  day  or  on  alternate  days,  so  as  to  clear  away  tena- 
cious mucus  from  the  stomach.  Chloral  is  useful  in  these  cases  by  its 
power  of  diminishing  reflex  action.  Excessive  vomiting  is  usually  found 
in  cases  where  the  laryngeal  spasm  is  extreme,  and  the  remedies  which 
are  useful  in  alleviating  this  symptom  have  also  a  beneficial  action  in 
checking  too  forcible  contraction  of  the  diaphragm.  Looseness  of  the 
bowels  is  usually  easily  controlled  by  a  dose  of  castor-oil.  In  this  coun- 
try diai-rhoea  seldom  becomes  troublesome,  but  in  warm  climates  during 
the  hot  season  choleraic  diarrhoea  may  supervene.  This  must  be  treated 
according  to  the  rules  laid  down  for  the  management  of  that  serious  con- 
dition. 

If  laryngismus  stridulus  comphcate  the  paroxysm,  bromide  of  am- 
monium or  potassium  (gr.  iij.)  may  be  given  with  atropia  two  or  three 
times  a  day  ;  and  the  same  treatment  is  useful  if  unwonted  nervous  excite- 
ment, or  signs  of  cerebral  disturbance,  indicate  the  imminence  of  a  convul- 
sive fit.  If  the  spasm  be  prolonged  and  seem  to  threaten  suffocation,  slip- 
ping the  child's  hands  into  cold  water  will  often  relax  the  glottis  at  once. 

Convulsions  must  be  treated  according  to  the  special  condition  from 
which  they  appear  to  have  arisen.  In  the  more  serious  form  of  eclamptic 
attack,  such  as  that  induced  by  collapse  of  lung,  catarrhal  pneumonia,  or 
thrombosis  of  intracranial  sinuses  and  veins,  the  treatment  must  be  directed 
against  the  complication  by  which  the  nervous  seizure  has  been  excited. 
Convulsions  set  up  by  pure  nervous  agitation,  or  by  partial  asphyxia  from 
violence  of  laryngeal  spasm,  are  usually  to  be  controlled  by  the  administra- 
tion of  chloral  in  the  quantities  already  indicated.  If  the  seizui-es  occur  in  a 
rickety  child,  and  appear  to  be  the  consequence  of  digestive  disturbance 
and  acidity  (a  not  uncommon  case),  a  dose  of  ipecacuanha  wine,  followed 
by  an  antacid  and  aromatic  mixture,  will  usually  put  an  end  to  them  at 
once. 

If  the  pulmonary  catarrh  become  severe  and  threaten  collapse  of  the 
lung,  prompt  steps  must  be  taken  to  ward  off  this  dangerous  comphcation. 
Stimulating  applications  should  be  applied  to  the  chest  and  back  ;  occa- 
sional emetics  should  be  given  to  aid  in  the  expulsion  of  mucus  ;  and  the 
child's  strength  must  be  supported  by  a  suitable  supply  of  alcoholic  stim- 
ulant. In  these  cases  alcohol  should  be  given  boldly.  A  young  child  in  a 
weakly  state  from  afeute  disease  will  respond  well  to  such  treatment,  and 
a  few  timely  doses  of  brandy-and-egg,  or  other  powerful  stimulant,  will 
quickly  give  him  renewed  strength  to  struggle  against  his  disease.  It  may 
be  necessary  to  give  a  teaspoonful  every  houi*,  or  even  half  hour,  until  the 
difficulty  is  overcome. 


128  DISEASE  IlSr   CHILDEE]^. 

If  catarrhal  pneumonia  supervene,  the  complication  must  be  treated 
upon  the  principles  laid  down  in  the  chapter  relating  to  that  subject. 

When  the  disease  is  at  an  end,  change  of  air  to  a  dry,  bracing  spot  or 
to  the  sea-side  is  of  importance.  Kemembering  the  frequency  of  glandular 
enlargements  and  the  danger  of  tuberculosis,  we  should  recommend  such 
measures  as  are  required  for  restoring  impaired  nutrition  and  replacing 
lost  strength.  Cod-liver  oil  is  very  valuable,  alcohol  is  of  service,  and  iron 
is  usually  indicated. 

The  symptoms  described  as  "mucous  disease,"  which  are  often  seen  in 
children  of  three  or  four  years  of  age  or  upwards  after  an  attack  of  whoop- 
ing-cough, are  quickly  removed  by  careful  regulation  of  the  diet.  The 
child  should  be  fed  upon  meat,  eggs,  fish,  poultry,  and  milk ;  and  potatoes, 
farinaceous  puddings,  fruit,  cakes,  sweets — all  articles,  in  fact,  capable  of 
affording  material  for  fermentation  must  be  strictly  forbidden.  A  mild 
aperient,  such  as  the  compound  liquorice  powder,  should  be  given  twice  a 
week  to  ensure  the  expulsion  of  excess  of  mucus  from  the  bowels  ;  and 
iron  with  alkalies,  or  iron  wine  with  compound  decoction  of  aloes  (aa  3  ij. 
for  a  child  of  five  years  of  age),  should  be  given  two  or  three  times  a  day, 
two  houi's  after  meals. 


JJart  2. 
GENERAL  DISEASE  NOT  INFECTIOUS. 


CHAPTER  I. 

RICKETS. 


Or  all  the  chronic  diseases  to  which  young  children  are  liable,  none  sur- 
passes in  interest  and  importance  the  one  now  to  be  considered.  The  fre- 
quency with  which  rickets  occurs,  the  variety  of  tissues  it  affects,  the  influ- 
ence it  exercises  upon  the  course  and  termination  of  intercurrent  maladies, 
and  the  distressing  and  often  fatal  consequences  which  its  presence  involves 
render  this  disease  especially  deserving  of  careful  study. 

Although  dissimilar  in  many  respects  from  the  class  of  so-called  dia- 
thetic diseases,  viz.,  those  which  arise  as  a  consequence  of  a  distinct  con- 
stitutional predisposition,  rickets  is  yet  a  general  affection,  for  it  impairs 
the  nutrition  of  the  whole  body.  Under  its  influence  growth  and  develop- 
ment are  arrested,  dentition  is  retarded,  the  bones  soften  and  become 
deformed,  the  muscles  and  ligaments  waste,  and  in  fatal  cases  alterations 
are  often  noticed  in  the  brain,  hver,  spleen,  and  lymphatic  glands.  The 
disease  usually  begins  in  infancy.  It  is  rare  under  the  age  of  six  months,, 
for  it  seems  very  doubtful  if  the  cases  of  so-called  congenital  rickets  are 
true  examples  of  the  disease.  At  the  eighth  month,  however,  it  begins  to 
be  common,  and  from  that  age  until  the  eighteenth  month  may  be  readily 
set  up  under  the  influence  of  causes  which  interfere  with  digestion  and  im- 
pede the  assimilation  of  food.  It  is  less  common  for  the  disease  to  develop 
in  children  who  have  been  in  good  health  up  to  the  age  of  eighteen  months, 
but  it  may  occur  at  any  time  between  that  age  and  the  seventh  year,  or 
even  in  still  older  subjects.  Although  beginning  at  a  very  early  age,  the 
disease  often  continues  for  several  years,  and  may  be  seen  existing  in  a 
marked  degree  in  children  thi-ee  or  four  years  old. 

Causation. — Rickets  is  the  direct  consequence  of  mal-nutrition  in  early 
hfe.  Its  causes  must  therefore  be  looked  for  in  all  the  diverse  agencies 
which  impair  the  nutrition  of  the  growing  frame.  The  most  imjDortant  of 
these  are,  no  doubt,  faults  of  feeding  and  hygiene.  Insufficient  or  unsuit- 
able food  stints  the  body  of  necessary  nourishment,  and  an  inadequate 
supply  of  fresh  air  renders  assimilation  defective  and  weakens  digestive 
power.  These  two  causes  are  most  commonly  found  united  in  the  poorer- 
quarters  of  large  cities.  An  infant  who  lives  amongst  other  children  in 
9 


130  DISEASE   IN   CHILDREN". 

one  small  room,  where  it  breathes  a  tainted  air  and  derives  its  only  nour- 
ishment  from  the  watery  breast-milk  of  a  weakly  mother,  with  the  addi- 
tion, perhaps,  of  a  little  gruel  or  sopped  bread  to  quiet  it  when  it  cries,  can 
only  escape  rickets  by  becoming  tubercular.  By  such  means  an  extreme  de- 
gree of  the  malady  will  jDrobably  be  produced.  But  similar  agencies,  al- 
though operating  in  a  milder  form,  will  produce  rickets  in  any  condition 
of  hfe.  It  is  not  imcommon  to  meet  with  examples  of  the  disease  in  well- 
to-do  families  where  the  child  has  been  kept  in-doors  for  fear  of  his  catch- 
ing cold,  and  has  been  supplied  with  farinaceous  compounds  largely  beyond 
his  powers  of  digestion.  Over-feeding  with  starchy  foods  is  a  fruitful 
cause  of  rickets.  The  giving  of  farinaceous  matters  in  excess,  or  at  a  time 
when  the  glandular  secretions  are  insufficient  for  its  digestion,  is  the  com- 
monest fault  committed  in  the  hand-feeding  of  infants.  Dr.  Buchanan 
Baxter,  who  tabulated  one  hundi'ed  and  twenty  consecutive  cases  of 
rickets,  found  that  in  many  of  them  the  disease  dated  from  the  time  when 
farinaceous  food  was  first  given.  It  is  probable  that  in  these  cases  the  oc- 
currence of  mal-mitrition  and  subsequent  rickets  is  due  not  so  much  to 
the  excess  of  starch  as  to  the  absence  of  the  more  nutritious  food  for 
which  the  starch  has  been  substituted.  Rickety  children  so  fed  are  often 
fat,  and  do  not,  to  the  inexperienced  eye,  convey  the  impression  of  being 
under-noiu-ished.  Examination,  however,  discovers  that  they  are  by  no 
means  strong  in  proportion  to  their  size.  Although  stout  they  are  weak, 
often  excessively  feeble  ;  and  it  is  evident  that  the  plumpness  of  the  child 
is  due  to  disproportionate  development  of  the  subcutaneous  fat.  This 
tissue  has  been  enormously  over-nourished  while  the  rest  of  the  body  has 
been  stinted  and  starved. 

The  time  of  weaning  is  often  a  starting-point  for  rickets,  for  the  breast- 
milk  is  usually  replaced  by  some  preparation  of  starch.  So  also  long- 
continued  suckling  may  induce  the  disease,  for  the  breast-milk  after  a 
time  ceases  to  satisfy  the  infant's  wants,  and  too  little  additional  nourish- 
ment is  supplied.  Therefore  whether  the  food  given  be  insufficient  in 
amount  or  indigestible  in  form  the  effect  is  the  same  :  the  child  is  starved 
and  rickets  becomes  develojDed. 

In  cases  where  the  child  hves  in  a  good  l^racing  au"  the  effects  of  an  un- 
suitable dietary  are  less  jDainfully  e'sddent.  In  dry  country  places,  where 
the  infant  spends  much  of  his  time  out  of  doors,  rickets  is  a  more  uncom- 
mon disease  than  it  is  in  localities  where  the  conditions  are  less  favoui'able 
to  health.  Want  of  sunlight,  want  of  cleanliness,  and  a  combination  of 
cold  and  damp  are  other  determining  causes  which  ai'e  not  without  their 
influence  in  the  production  of  rickets.  All  these  causes  must  no  doubt  act 
with  especial  energy  in  the  case  of  infants  who  are  naturally  weakty,  or 
whose  strength  has  been  already  reduced  by  some  exhausting  disease. 
There  are,  therefore,  many  conditions  which  predispose  to  the  complaint. 
Feebleness  of  constitution  on  the  part  of  the  j)arents  will,  no  doubt,  have 
an  influence  in  this  respect,  for  weakly  parents  are  not  likely  to  beget  con- 
stitutionally healthy  children.  Moreover,  a  weakly  mother  is  usually  unable 
to  nurse  her  baby  ;  and  hand-feeding,  unless  conducted  with  extreme  care 
and  discretion,  is  often  unsatisfactory.  A  very  large  proportion  of  rickety 
infants  are  bottle-fed. 

Hereditary  tendency  is  considered  by  some  observers  to  be  an  element 
in  the  etiology  of  the  disease.  In  the  case  of  so  common  an  affection  it 
must  no  doubt  often  happen  that  the  father  or  mother  of  the  patient  has 
been  previously  affected  in  a  similar  way  ;  but  that  a  parent  who  had  been 
rickety  in  childhood  should  give  birth  to  a  weakly  infant,  and  that  this  in- 


EICKETS — CAUSATION.  131 

fant,  brought  up  in  violation  of  all  the  rules  of  health,  should  develope 
rickets,  is  surely  but  slender  evidence  in  favour  of  the  hereditary  trans- 
mission of  the  disease.  Supporters  of  this  theory;  usually  point  to  the 
cases  of  so-called  ''congenital  rickets"  as  instances  of  the  inherited  form 
of  the  disease  ;  but,  as  is  hereafter  explained,  there  are  reasons  for  exclud- 
ing these  cases  from  the  class  of  true  rickets. 

The  relation  which  exists  between  rickets  and  congenital  syphilis  has 
vyithin  the  last  few  3'ears  been  brought  into  great  prominence.  Si.  Parrot 
has  laboured  to  show  that  rickets  is  always  the  consequence  of  an  heredi- 
tary syphilitic  taint.  The  arguments  of  this  observer  in  favour  of  his  view 
are  derived  chiefly  from  morbid  anatomy.  He  points  in  particular  to  the 
anatomical  changes  observable  in  the  epiphyseal  ends  of  the  long  bones  in 
the  two  diseases  as  evidence  of  the  specific  nature  of  rickets.  But  the  latter 
is  not  only  a  disease  of  the  bones  ;  and  although  the  epiphyses  in  the  two 
cases  may  present  a  certain  similarity  of  lesion,  there  are  other  alterations  of 
structure  in  rickets  which  are  different  from  those  of  syphilis.  Moreover, 
the  general  symptoms,  especially  the  pecuhar  tendency  to  functional  ner- 
vous disorders,  have  no  counterpart  in  the  specific  disease.  Again,  rickets 
is  constantly  met  with  in  cases  where  the  most  careful  inquiry  and  most 
minute  examination  fail  to  detect  any  history  of  venereal  taint  in  the 
parents  or  sign  of  it  in  their  offspring.  The  disease  is  common  in  locahties 
where  congenital  syphilis  is  rare,  and  rare  in  places  where  the  latter  is 
common.  It  is  met  with  in  animals  as  well  as  the  human  subject,  and  is 
produced  in  them  by  faulty  hygiene  and  bad  feeding  as  it  is  in  the  child. 
But  it  is  needless  to  multiply  arguments  against  the  untenable  hypothesis 
advanced  by  this  distinguished  pathologist. 

Still,  although  it  cannot  be  allowed  that  rickets  is  caused  by  syphilis, 
syphilitic  infants  may  become  rickety ;  and  it  is  probable  that  a  parent 
weakened  by  a  former  syphilis  may,  without  transmitting  the  taint  to  his 
offspring,  beget  a  child  of  feeble  constitution  in  whom  rickets  can  be  easily 
induced.  But  in  both  these  cases  injudicious  feeding  and  insanitary  con- 
ditions must  come  into  operation  before  the  disease  can  occur. 

A  pronounced  tubercular  disposition  appears  to  have  a  protective  power 
against  rickets  ;  for  although  weakly,  phthisical  parents  may  give  birth  to 
feeble  infants  who  readily  fall  victims  to  rickets,  it  is  rare  to  find  the  lat- 
ter disease  in  a  family  where  other  members  have  died  of  tubercular  men- 
ingitis or  other  form  of  pure  tuberculosis — unless,  indeed,  the  tubercular 
mischief  has  occurred  secondarily  to  rickets.  The  reason  of  this  immunity 
seems  to  be  that  the  causes  which  are  capable  of  setting  up  rickets  will  in- 
duce tuberculosis  in  a  child  predisposed  to  this  form  of  illness  and  very 
C[uickly  bring  his  life  to  a  close. 

How  it  is  that  these  causes  give  rise  to  rickets  is  still  undecided.  It 
has  been  shown  by  the  experiments  of  Friedleben  that  a  diet  deficient  in 
X^hosphoric  acid  and  the  lime  salts  is  not  capable,  as  was  at  one  time  sup- 
posed, of  inducing  rickets  ;  indeed,  it  seems  probable  that  the  essence  of 
the  process  is  not  a  mere  deficiency  of  lime  in  the  bones,  but  an  irritation 
of  the  bone-making  tissue.  It  is  asserted  by  Heitzman  that  lactic  acid  ex- 
ei'cises  an  irritating  influence  upon  the  osteoplastic  tissue,  and  that  it  is 
this  influence,  combined  with  a  deficiency  in  lime  salts,  which  induces  the 
disease.  There  is  little  doubt  that  lactic  acid  is  abundantly  generated  in 
the  deranged  digestive  organs  of  rickety  children,  for  this  acid  has  been 
detected  in  their  urine.  If  Heitzman's  theory  be  correct,  the  acid  excites 
irritation  in  the  osteoplastic  tissue,  and  at  the  same  time  dissolves  and 
helps  to  ehminate  the  calcareous  matter  deposited  in  the  bones.     If,  in  ad- 


132  DISEASE  IN   CHILDRE]^r. 

dition,  the  supply  of  lime  salts  be  actually  reduced,  rickets  is  set  up  witli 
still  greater  certainty. 

Morbid  Anatomy. — In  looVing  at  a  case  of  well-marked  rickets  the  eye 
is  at  once  arrested  by  the  enlargement  of  the  eiDiphyseal  ends  of  the  long 
bones  and  the  deformities  of  the  skeleton  which  result  from  softening  of 
the  osseous  framework.  In  rickets  the  bones  are  affected  in  three  ways. 
Growth,  although  not  completely  arrested,  is  retarded  and  rendered 
irregular  ;  ossification  of  jDarts  still  remaining  cartilaginous  is  interfered 
with,  and  bone  ah-eady  ossified  is  softened.  When  a  longitudinal  section 
is  made  of  one  of  the  long  bones  the  whole  structure  appears  deeply  red- 
dened from  intense  congestion.  The  epiphj'sis  is  very  large,  and  the  in- 
crease in  size  is  due  chiefly  to  an  enormous  development  of  the  cartilage, 
which  is  preparing  for  the  reception  of  the  calcareous  salts.  The  layer  of 
cartilage  into  which  the  new  bone  is  advancing  is  called  the  zone  of  calcifi- 
cation. That  next  in  order,  in  which  the  corpuscular  elements  arrange 
themselves  in  vertical  columns  in  j)reparation  for  the  approach  of  the 
earthy  dej^osit,  is  called  the  zone  of  proliferation.  These  two  zones  are 
greatly  thickened  and  are  not  separated,  as  would  be  the  case  in  the  bone 
of  a  healthy  child,  by  a  well-defined  straight  line  of  demarcation.  In  the 
rickety  epiphysis  the  new  bony  tissue,  instead  of  advancing  by  regTilar 
ste^DS  into  the  zone  of  calcification,  no  one  point  being  in  advance  of  an- 
other, shoots  up  irregularly,  so  that  lines  or  little  islets  of  calcification  are 
seen  far  up  in  the  prohferating  zone,  while  on  the  other  hand  specks  and 
streaks  of  uucalcified  cartilage  are  left  far  below  the  hne  of  earthy  deposit 
completely  surrounded  by  bone.  Moreover,  medullary  spaces  are  formed 
in  unusual  places,  and  aj^pear  even  in  the  prohferating  zone  of  cartilage 
far  in  advance  of  the  margin  of  ossification.  The  cartilage  cells  become 
the  seat  of  calcareous  impregnation, '  and  are  in  many  cases  converted  into 
bone  corpuscles.  Small  isolated  masses  of  Hme  can  also  often  be  seen 
scattered  through  the  matrix — enough  in  many  cases  to  give  a  dotted  ap- 
pearance to  a  section  of  the  cartilage. 

Changes  similar  to  those  described  in  the  epiphyses  take  place  at  the 
surface  of  the  shaft  of  the  long  bones  and  in  the  flat  bones.  The  perios- 
teum becomes  excessively  thick  and  very  vascular,  and  is  connected  so 
firmly  with  the  bone  beneath  that  it  cannot  be  detached  without  fi'agments 
of  the  latter  being  stripped  away  with  it.  Its  connective-tissue  corpuscles 
undergo  rapid  proliferation  and  become  transformed  directly  into  bone 
corpuscles.  The  calcifying  process  is  irregular  here  as  it  is  in  the  epi- 
physes, so  that  layers  of  firm  bony  tissue  are  interspersed  with  others 
composed  of  a  fibrous  matrix  containing  connective  tissue  or  bone  cor- 
puscles and  medullary  spaces.  In  the  flat  bones,  especially  those  of  the 
skull,  the  irregularity  with  which  calcareous  matter  is  deposited  is  well 
seen.  The  new  jjorous  bone  occupies  chiefly  the  surface  and  edges.  In 
the  cranial  bones  a  special  change  is  often  found.  In  certain  spots  the 
bone  becomes  excessively  thin  and  trausjDarent  (cranio-tabes).  This  con- 
dition is  due  to  deficient  deposit  of  hme  salts  in  the  external  layers  and 
absorption  of  the  soft  tissue  in  places,  here  and  there,  from  the  pressure  of 
the  brain. 

Bones  in  which  ossification  is  thus  delayed  and  perverted  are  usually 
soft.     The  softening  is  the  consequence  of  the  smaller  projDortion  of  earthy 

'  It  lias  been  doubted  whetber  this  cbange  occurs  in  healtby  ossification,  for  in  tbe 
noi-mal  process  tbe  calcification  of  tbe  intercellular  matrix  wbicli  surroiands  tbe  carti- 
lage cells  conceals  tbe  latter  from  view.  In  rickety  bone  tbe  calcifying  granules  are 
deposited  first  in  tbe  cells,  so  tliat  tbe  cbanges  in  tbem  can  be  distinctly  seen. 


RICKETS — MOEBID   ANATOMY.  133 

salts  they  contain  and  the  larger  percentage  of  organic  matter.  But  the 
deficiency  of  lime  salts  is  due  not  to  their  removal  after  deposition,  but  to 
the  sluggishness  with  which  they  are  deposited.  The  corpuscular  elements 
of  the  periosteum  are  proliferated  in  large  quantities,  and  the  new  matter 
is  but  slowly  and  imperfectly  converted  into  bone.  The  circumference  of 
the  shaft,  therefore,  consists  in  gi-eat  measure  of  spongy  lamellse  which  are 
only  partially  ossified.  All  this  time  in  the  interior  of  the  bone  the  normal 
enlargement  of  the  medullary  canal  by  absorption  still  continues,  so  that 
as  long  as  the  rickety  process  is  active  the  proportion  of  properly  con- 
structed osseous  matter  containing  its  due  percentage  of  earthy  salts  is 
continually  diminishing.  Such  a  bone  must  necessarily  be  yielding  and 
subject  to  ready  distortion.  This,  however,  is  not  the  only  cause  of  the 
bone  deformities.  According  to  Strekoff,  the  osseous  trabeculse  have  an 
abnormal  arrangement  in  rickety  bone.  They  are  disposed  radially  in- 
stead of  concentrically.  He  maintains  that  this  irregularity  further  di- 
minishes their  power  of  resistance  to  external  pressure  and  is  an  additional 
source  of  weakness. 

At  the  height  of  the  disease  the  bones,  besides  being  softer,  are  speci- 
ficaUy  lighter  than  natural,  and  contain  an  undue  proportion  of  fatty 
matter.  Moreover,  the  cartilage  contains  a  high  percentage  of  water. 
The  bone  on  analysis  has  been  shown  to  consist  of  33  to  52  per  cent,  of 
earthy  salts,  instead  of  63  to  65  as  in  health,  and  its  animal  matter  is  said 
to  yield  no  gelatine  on  boihng. 

When  the  disease  becomes  arrested,  ossification  in  the  soft,  newly 
formed  tissue  takes  place  rapidly.  The  loose  spongy  structure  closes  up 
and  becomes  thick  and  hard,  and  the  whole  bone  is  heavy  and  dense. 

The  morbid  changes  in  the  osseous  system  form,  no  doubt,  the  most 
characteristic  feature  of  the  rickety  state  :  but  rickets  is  not  merely  a  dis- 
ease of  the  bones.  In  addition,  various  pathological  changes  are  discovered 
in  the  bodies  of  children  who  have  died  while  suffering  from  this  affection. 
In  some  the  liver,  spleen,  and  lymphatic  glands  are  found  diseased,  the 
muscular  structure  is  altered  in  bad  cases,  the  brain  may  be  affected,  and 
the  urine  almost  invariably  exhibits  pathological  characters. 

The  alterations  in  the  liver,  spleen,  and  lymphatic  glands  are  by  no 
means  present  in  every  case,  or  even  in  every  marked  case  of  the  disease. 
The  affected  organs  are  enlarged,  tough,  and  solid  to  the  touch,  and  heavy 
out  of  proportion  to  their  size.  The  change  is  usually  most  marked  in  the 
spleen.  Dr.  Dickinson  considers  it  to  be  due  to  no  "new  growth  or  infil- 
trated deposit,"  but  to  a  hyperj^lasia  of  the  normal  tissue  of  the  organ,  and 
chieily  of  the  interstitial  connective  tissue.  The  fibrous  and  epithehal  ele- 
ments are  hypertroj)hied,  and  at  the  same  time  their  earthy  salts  are  de- 
ficient in  quantity.  In  the  limr  the  fibroid  sheath  within  the  smaller  portal 
canals  is  twice  its  natural  size,  and  in  the  glandular  structure  the  yeUowish 
acini  are  bounded  by  a  thin  pinkish  or  grayish  line.  In  the  spleen  the  in- 
terstitial connective  tissue  may  become  so  hypertrophied  that  the  trabeculae 
are  as  thick  as  the  spaces  they  enclose.  In  the  meshes  the  corpuscles  are 
seen  by  the  microscope  to  be  crowded  together.  The  organ  is  hard  and 
resistant,  so  that  it  can  be  cut  with  the  utmost  ease  into  thin  sections.  Its 
surface  is  deep  red  or  pui'ple  in  coloiu-,  with  smooth  white  spots  from  en- 
larged Malpighian  corpuscles.  Its  section  is  deep  red  mottled  with  pale 
buff  coloin-.  But  little  blood  can  be  squeezed  from  the  cut  surface.  The 
lymphatic  glands  are  sometimes  also  enlarged  and  hard.  They  are  white 
and  opaque  on  section  from  accumulation  of  then-  cellular  contents. 

Enlargement  of  the  hver  in  rickets  is  not  always  the  consequence  of  the 


134  DISEASE   IN   CHILDEEN". 

pathological  condition  described.  If  a  rickety  child  be  mucli  wasted  from 
intestinal  catarrh  or  other  digestive  trouble,  the  liver  may  be  swollen  from 
fatty  infiltration.  If  he  have  been  subject  to  repeated  pulmonarj^  catarrhs 
vsdth  great  interference  ■v^dth  the  respii'atory  function,  the  organ  ma}'  be 
enlarged  from  chi'onic  congestion.  So  also  turgescence  of  the  spleen  may 
be  found  unaccom23anied  by  any  appreciable  lesion  of  the  liver  or  lymjihatic 
glands.  In  some  cases  the  increase  in  size  of  the  organ  appears  to  be  due, 
as  in  the  case  of  the  liver,  to  a  chronic  congestive  process  which  causes  a 
large  development  of  hyaline  fibroid  material.  In  others  the  spleen  seems 
to  be  the  seat  merely  of  simple  hj-perplasia  and  presents  the  ordinary 
characters  of  h^-pertrophy,  such  as  are  seen  in  some  cases  of  inherited  s^^^h- 
ihs  and  in  the  ague  cachexia.  This  form  of  enlargement  is  referred  to 
elsewhere  (see  page  238). 

The  muscles  have  been  noticed  by  Sii*  William  Jenner  to  be  small,  pale, 
flabby,  and  soft.  Their  fibres  under  the  microscope  are  softer  and  paler 
than  natiu'al,  with  the  strife  very  indistinctly  marked.  The  brain  is  some- 
times small  and  shrunken,  so  that  fluid  is  thrown  out  to  fill  up  the  space 
left  vacant  in  the  skuU  cavity.  It  is  also  sometimes  enlarged,  so  much  so, 
in  some  cases,  as  to  cause  distention  of  the  cranium.  Dr.  Hilton  Fagge  has 
referred  to  a  case  which  was  taken  to  be  one  of  advanced  hydrocephalus 
until  an  examination  of  the  body  after  death  showed  that  the  brain  filled 
up  the  cranial  cavity  eompletety.  In  such  cases  the  organ,  although  en- 
larged, has  a  healthy  appearance  and  is  of  natm-al  consistence.  The  hj-per- 
trophy  is  said  to  be  in  the  neuroglia  without  any  increase  in  the  nerve- 
elements. 

The  urine  contains  an  increased  proportion  of  phosphate  of  lime,  and 
lactic  acid  has  been  found  in  it  by  some  observers.  The  secretion  is  pale 
in  colour  and  often  deposits  crystals  of  oxalate  of  lime.  Often,  also,  as  is 
so  commonly  the  case  in  childi-en  in  whom  acid  is  largely  generated  from 
fermentation  of  food,  crystals  of  uric  acid  and  even  considerable  quantities 
of  red  sand  may  be  passed  fi-om  the  kidneys. 

In  addition  to  the  above  jDathological  conditions,  which  may  be  con- 
sidered to  arise  dii'ectly  from  the  general  disease,  there  are  others  which 
may  be  looked  upon  as  accidental  since  they  are  induced  mechanically  by 
the  deformities  of  the  thorax  resulting  from  the  softening  of  the  ribs.  In 
all  cases  of  distortion  of  the  framework  of  the  chest  two  pulmonary  lesions 
are  invariabty  present.  These  are  emphj'sema  and  collapse.  The  emphy- 
sema is  seated  at  the  anterior  borders  of  the  lungs,  and  extends  backwards 
for  about  three-quarters  of  an  inch  from  their  free  margins.  Immediately 
outside  this  hne  of  dilated  lung  tissue  is  a  line  of  collapse  which  separates 
it  fi'om  the  healthy  pulmonary  substance  beyond.  These  lesions  occxu-  to- 
gether and,  although  not  dependent  one  upon  another,  are  produced  by 
the  same  mechanical  means.  During  the  act  of  inspiration  the  softened 
ribs  sink  in,  and  the  pressure  of  the  enlarged  ends  of  the  ribs  compresses 
the  lung  tissue  with  which  they  are  in  contact  so  as  to  prevent  its  expan- 
sion b}'  the  air  which  inflates  the  remainder  of  the  lung.  While,  however, 
the  diameter  of  the  chest  is  narrowed  laterally,  its  antero-posterior  diameter 
is  increased  by  the  protrusion  of  the  sternum.  Consequently  the  alveoli 
of  the  anterior  borders,  immediately  behind  the  breast-bone,  are  dis- 
tended by  the  air  which  is  forced  into  this  part  to  fill  up  the  resulting 
space. 

Pulmonary  collapse  is  not  always  limited  to  the  parts  of  the  lung  cor- 
responding to  the  ends  of  the  ribs.  There  is  often  to  be  seen,  in  addition, 
a  certain  amount  of  atelectasis  at  the  bases  of  the  lujigs  behind.     Collapse 


RICKETS — MORBID   ANATOMY.  135 

fit  this  part  of  the  lung  is  due  to  pulmonary  catarrh  and  plugging  of  an 
air-tube  with  mucus.     Its  mechanism  is  described  elsewhere  (see  p.  465). 

The  enlarged  ejDiphyses  of  the  ribs,  besides  their  effect  upon  the  lung 
tissue,  are  also  the  cause  of  the  patches  of  circumscribed  opacity  seen  on 
the  visceral  surface  of  the  pericardium  and  on  the  spleen.  That  on  the 
pericardium  is  situated  on  the  left  ventricle  a  little  above  the  apex  of  the 
heart.  At  this  point  the  heart  at  each  beat  comes  into  contact  with 
the  nodule  of  the  fifth  rib.  That  on  the  spleen  is  produced  in  the  same 
way  by  attrition,  the  organ  as  it  rises  and  falls  in  respiration  being 
rubbect  against  a  similar  costal  projection.  In  each  case  the  white  patch  is 
limited  to  the  fibrous  layer. 

From  a  consideration  of  the  morbid  changes  discovered  in  the  bodies 
of  rickety  children,  it  is  evident  that  the  disease  is  a  very  special  one,  in- 
volving very  wide-spread  lesions  of  structure.  Attention  has  lately  been 
directed  to  the  whole  subject  of  bone  changes  in  the  young  subject,  and 
it  is  asserted  that  many  cases  in  which  bone  softening  has  been  pronounced 
are  not  real  examples  of  rickets,  but  ought  rather  to  fall  under  the  head- 
ing of  osteo-malacia  ;  the  osseous  changes  resembhng  closely  those  observ- 
able in  cases  of  osteo-malacia  in  the  adult.  The  question  is  of  importance, 
for  the  pathology  of  the  two  conditions  is  essentially  dissimilar.  In  osteo- 
malacia softening  is  the  consequence  of  a  removal  of  the  earthy  constitu- 
ents from  perfectly  formed  bone.  In  rickets  ossification  is  incomplete, 
and  much  new  material  is  thrown  out  which  undergoes  very  imperfect 
calcification.  The  cjuestion  can  only  be  decided  by  a  careful  study  of  the 
morbid  appearances.  In  the  case  of  a  rickety  little  girl,  aged  eighteen 
months,  described  by  Dr.  Rehn  of  Frankfort,  there  was  marked  distortion 
and  softening  of  many  of  the  long  bones,  with  other  signs  usually  consid- 
ered characteristic  of  rickets.  The  disease,  however,  was  judged  to  be 
osteo-malacia  on  the  ground  that  although  softening  was  a  marked  feature 
in  the  bones,  the  epiphyseal  ends  were  only  moderately  swollen,  and  in 
the  bones  of  the  lower  extremities  were  hardly  swollen  at  all.  Moreover, 
the  whole  skeleton  was  excessively  thin  and  the  lower  extremities  were 
cjuite  straight.  There  was,  however,  a  considerable  formation  of  soft  peri- 
osteal deposit ;  and  a  rickety  element  in  the  case  was  admitted.  It  is  pos- 
sible that  true  osteo-malacia  may  be  grafted  on  a  case  of  rickets,  as  is 
supjjosed  by  Dr.  Eehn  to  have  happened  in  the  instance  referred  to,  but 
further  observations  are  to  be  desired  before  any  definite  conclusion  in 
the  matter  can  be  arrived  at. 

Before  closing  the  subject  of  the  pathology  of  rickets  a  few  words  may 
be  said  with  regard  to  the  cases  of  so-caUed  "  congenital  rickets."  This 
term  is  applied  to  a  condition  in  which  the  limbs  of  a  new-born  child  are 
found  to  present  peculiar  characters.  The  shafts  of  the  bones  are  short 
and  thickened,  and  may  be  found  bent  or  even  broken.  At  the  same  time 
the  epiphyses  are  swollen,  soft,  and  quite  cartilaginous.  The  condition, 
however,  differs  materially  from  true  rickets,  and  has  been  compared  by 
Eberth  to  that  found  in  cretinous  children.  In  all  recorded  cases  where 
the  posi-mortem  appearances  have  been  noted  the  shafts  of  the  bones 
have  been  found  much  ossified  and  remarkably  thick  and  stunted.  This 
peculiarity  gives,  of  coui'se,  a  curious  shortness  to  the  limbs.'  The  dia- 
physes,  instead  of  being  imperfectly  ossified  as  in  rickets,  with  great 
porosity  of  the  medullary  parts  of  the  bone  and  thickness  of  the  perios- 


'  In  a  case  described  by  Dr.  Barlow  the  upper  limbs  reached  only  to  the  umbili- 
cus, and  the  lower  extremities  measured  no  more  than  five  inches  in  length. 


136  DISEASE  IN   CHILDEEN. 

teum,  are  excessively  hard  and  compact.  Fibrous  tissue  derived  from  the 
inferior  layers  of  the  periosteum  intrudes  between  the  e^^iphysis  and  the 
shaft.  The  epiphyses,  also,  are  enlarged  generally  and  not  only  at  the  line 
of  calcification,  as  in  rickets  ;  and  their  microscopical  characters  present 
sensible  differences.  In  a  case  recorded  by  Urtel  the  cartilage  cells  in  the 
epiphyses  were  found  lying  confusedly  together.  As  they  approached  the 
diaphysis  they  were  seen  to  become  flatter,  especially  in  the  peripheral 
portions,  and  finally  passed  into  the  layer  of  connective  tissue  which  sep- 
arated the  greater  part  of  the  epiphysis  from  the  shaft  of  the  bone.  The 
resemblance  between  these  cases  and  cretinism  is  displayed  not  only  by 
the  stunting  and  firm  ossification  of  the  diaphyses.  There  is  the  same 
tendency  to  early  union  by  ossification  of  the  basi-occipital  and  post- 
sphenoidal  bones.  Some  specimens  of  "congenital  rickets  "  preserved  in 
the  Museum  of  the  Royal  College  of  Surgeons  exhibit  this  pecuharity, 
and  in  others,  where  the  soft  parts  remain  intact,  many  of  the  facial  char- 
acteristics of  the  cretin  are  also  to  be  observed. 

Symptoms. — As  might  be  expected  in  a  disease  which  arises  as  a  direct 
consequence  of  faulty  nutrition,  the  symptoms  proper  to  rickets  are  usu- 
ally preceded  by  others  indicating  a  general  interference  with  the  nutritive 
processes.  Digestive  derangements  are  common,  but  these  comparatively 
seldom  consist  in  attacks  of  severe  or  repeated  vomiting  or  diarrhoea.  In 
most  cases  the  derangement  is  limited  to  a  lessening  of  digestive  power,  so 
that  the  motions,  without  being  actually  loose,  are  more  frequent  than 
natural.  They  are  large,  pasty-looking,  and  offensive  from  the  quantity  of 
farinaceous  and  curdy  matters  which  are  passing  undigested  out  of  the 
body.  At  this  time  the  child  is  often  irritable  and  fretful.  His  belly  may 
be  swollen  from  flatulent  distention,  and  he  frequently  cries  with  pains 
in  the  abdomen.  For  this  reason  he  may  be  often  found  asleep  in  his  cot 
resting  on  his  chest,  or  supported  on  his  knees  and  elbows  with  his  head 
bui'ied  in  the  pillow.  The  urine  is  often  very  acid  and  causes  uneasiness 
in  mic,turition.  If  the  child  perspkes  copiously  the  renal  secretion  may 
contain  considerable  quantities  of  uric  acid  sand. 

Unless  by  judicious  treatment  and  diet  the  alimentary  canal  be  restored 
to  a  healthy  state  the  child,  although  often  still  plump  to  the  eye,  becomes 
pale  and  flabby.  Then,  after  an  intei^val  which  varies  in  duration  according 
to  the  natural  strength  of  the  patient  and  the  more  or  less  wholesomeness 
of  his  surroundings,  the  early  symptoms  are  noticed.  The  onset  of  the 
disease  is  announced  by  three  special  symptoms.  The  child  begins  to 
sweat  about  the  head  and  neck  ;  he  throws  off"  his  coverings  at  night  and 
lies  naked  in  his  cot ;  and  begins  shortly  afterwards  to  exhibit  uneasiness 
if  much  danced  about  in  his  nurse's  arms  or  handled  without  the  utmost 
gentleness. 

The  sweating  is  profuse  and  occurs  principally  during  sleep.  At  night 
beads  of  moisture  may  be  seen  standing  on  his  brows,  and  the  sweat 
trickles  off  his  head  on  to  the  pillow,  which  is  often  saturated  by  the  secre- 
tion. If  the  child  fall  asleep  in  the  day-time,  or  even  if  he  exert  himself 
much  while  awake,  the  same  phenomenon  may  be  noticed.  The  irritation 
of  this  perspiration  often  gives  rise  to  a  crop  of  miliaria  about  the  neck, 
behind  the  ears,  and  on  the  forehead.  The  superficial  veins  of  the  temples 
are  full,  the  jugular  veins  are  unusually  visible,  and  the  carotid  arteries 
may  be  felt  to  pulsate  strongly. 

The  desire  of  the  child  to  lie  cool  at  night  comes  on  almost  at  the  same 
time  with  the  preceding,  and  may  be  observed  in  the  coldest  weather.  It 
is,  indeed,  a  frequent  cause  of  catarrh  in  these  patients,  and  I  have  seen 


KICKETS — SYMPTOMS.  137 

many  cases  in  whicli  continued  looseness  of  the  bowels  was  apparently 
maintained  by  repeated  chills  so  contracted.  For  the  same  reason  a  fre- 
quent cough  from  pulmonary  catarrh  is  a  common  symptom. 

General  tenderness  usually  begins  to  be  noticed  at  a  certain  interval 
after  the  two  other  symptoms  which  have  been  mentioned.  It  is  shown  by 
unusual  sensitiveness  to  even  slight  jpressure,  and  appears  to  be  seated  in 
the  muscles  as  well  as  the  bones.  The  child  cries  if  lifted  up  at  all 
abruptly  or  subjected  to  any  jolt  or  jar,  and  prefers  to  lie  quietly  in  his 
cot  or  on  the  lap  of  his  nurse.  This  sjanptom  seldom  occui's  until  the 
osseous  changes  are  well  marked.  It  is  accompanied  by  uneasiness  or 
pain  about  the  head,  which  is  indicated  by  a  monotonous  movement  of  the 
head  from  side  to  side  upon  the  pillow.  The  hair  covering  the  occiput  is 
often  worn  away  by  this  constant  movement,  and  the  bareness  of  the  back 
of  the  scalp  from  this  cause  is  a  very  characteristic  symptom.  Tenderness 
is  not  always  noticed.  It  is  usually  confined  to  cases  where  the  disease  is 
severe.  In  the  mild  cases,  which  are  shown  merely  by  a  shght  enlarge- 
ment of  the  wrists  and  ankles,  without  any  apparent  softening  of  the  bones, 
the  symptom  is  usually  absent.  • 

The  bone  changes  consist  in  an  enlargement  of  the  epiphyseal  ends  of 
the  long  bones,  in  a  thickening  of  the  flat  bones,  and  in  a  general  softening 
of  all.  The  enlargement  of  the  ends  of  the  bones  occupies  the  point  of 
junction  of  the  shaft  with  the  ei^iphysis.  Both  extremities  of  the  bone  may 
suffer,  but  the  change  is  naturally  most  obvious  in  the  part  which  is  near- 
est to  the  surface.  The  ribs  at  their  sternal  ends  are  usually  the  first  to  be 
affected  ;  then  the  bones  of  the  wrists.  As  a  rule,  the  epiphyseal  swelhng 
is  more  marked  in  the  bones  of  the  upper  extremities  than  it  is  in  those 
of  the  lower.  The  thickening  of  the  flat  bones  is  well  seen  in  the  bones  of 
the  cranium,  and  the  softening  of  all  the  bones  is  one  of  the  causes  of  the 
deformities  of  the  trunk  and  limbs  which  are  so  common  in  early  life.  It 
must  not,  however,  be  supposed  that  every  case  of  rickets  ends  in  softening 
and  distortion.  All  degrees  of  severity  of  the  disease  may  be  met  with, 
and  in  mild  cases  softening  and  the  consequent  deformities  of  bone  are 
entirely  absent.  Even  in  more  severe  cases  we  must  not  expect  in  every 
instance  to  find  all  the  symptoms  to  be  enumerated.  In  one  child  the 
epiphyseal  swellings  attract  most  attention  ;  in  another  the  softening  of 
the  bones.  In  some  the  chest  is  excessively  distorted  and  the  bones 
of  the  limbs  are  comparatively  straight.  In  others  the  limbs  are  gi'eatly 
twisted  while  the  thorax  is  but  little  altered  from  the  normal  shape.  These 
differences  are  said  by  Baginsky  to  be  determined  by  the  part  of  the 
skeleton  in  which  growth  happens  to  be  most  active  at  the  time  of  the 
attack. 

In  a  pronounced  case  of  rickets  the  effect  of  the  bone  lesions  is  very 
striking  and  jDeculiar  : 

The  skull  is  large  with  a  long  antero-posterior  diameter,  and  often,  on 
account  of  the  comparatively  small  size  of  the  face,  looks  larger  than  it 
really  is.  The  forehead  is  square  from  exaggeration  of  the  bosses  of  the 
frontal  bones,  and  is  sometimes  very  prominent  from  the  development  in 
the  bone  of  cellular  cavities.  The  fontanelle  is  large  and  remains  open 
long  after  the  end  of  the  second  year.  Sometimes,  if  the  size  of  the  brain 
is  increased,  or  there  is  excess  of  fluid  in  the  skull  cavity,  the  sutures  in 
connection  with  the  fontanelle  can  be  felt  to  be  more  or  less  distinctly 
gaping.  On  account  of  the  thickening  of  the  edges  of  the  flat  bones  the 
margins  of  the  sutures  and  fontanelle  are  elevated,  so  that  the  latter  feel 
depressed  and  the  sutures  are  indicated  by  furrows.     The  posterior  fon- 


138  DISEASE   IN   CHILDREN. 

tan  elle  has  usually  disappeared  before  the  beginning  of  the  iUness,  but  in 
extreme  cases,  where  the  disease  began  esirly  and  the  symptoms  are  pro- 
nounced, it  may  be  felt  to  be  still  unclosed. 

In  every  case  of  rickets  the  condition  known  as  "  cranio-tabes "  and 
described  by  Elsasser  should  be  searched  for.  It  is  best  detected  by 
pressing  gently  with  the  tips  of  the  fingers  on  the  posterior  surface  of  the 
head.  If  cranio-tabes  be  present,  spots  will  be  felt  where  the  bone  is  thin, 
soft,  and  elastic,  as  if  at  this  point  it  had  been  converted  into  tightly 
stretched  parchment.  The  spots  are  seldom  larger  than  the  diamet^er  of  a 
good-sized  pea,  and  are  usually  confined  to  the  occipital  bone.  They  are 
caused  by  absorption  of  the  imperfectly  ossified  bone  from  its  compression 
between  the  pillow  and  the  brain  as  the  child  lies  in  his  cot.  They  may 
be  met  with  as  soon  as  the  third  month  of  life,  and  are  said  to  be  the  ear- 
liest sign  of  the  disease. 

A  rickety  child's  hair  is  usually  thin,  and  is  often  kept  moist  by  the 
copious  perspirations  to  which  the  head  is  subject  whenever  the  patient 
falls  asleep.  In  most  rickety  children  a  systohc  mui-mur  of  variable  inten- 
sity can  be»heard  with  the  stethoscope  applied  over  the  fontanelle.  Ac- 
cording to  Senator,  the  symptom  merely  shows  that  an  ossified  membrane 
is  better  fitted  than  the  cranial  bones  to  transmit  to  the  ear  sounds  gener- 
ated in  the  cerebral  vessels.  There  is  no  doubt  that  it  is  rarely  heard  in 
children  in  whom  the  fontanelle  has  closed.  The  murmur  is  sometimes 
curiously  loud.  Not  long  ago  a  pallid,  flabby  little  girl,  between  two  and 
three  years  old,  the  subject  of  rickets,  was  brought  to  me  from  the  coun- 
try on  account  of  a  strange  noise  which  was  heard  at  times  to  proceed 
from  her  head.  The  child  had  cut  aU  her  teeth,  but  was  very  weak  on  her 
legs.  She  was  subject  to  attacks  of  stiidulous  laryngitis.  The  fontanelle 
was  not  quite  closed.  Her  heart  and  lungs  were  healthy.  It  was  said 
that  in  this  child  a  noise  like  "  the  purring  of  a  kitten,"  not  continuous, 
but  distinctly  interiuittent,  "like  a  pulsation,"  could  be  heard  at  times.  It 
was  loudest  at  the  right  side  of  the  head.  It  was  not  especially  loud  after 
exertion,  and  was  only  occasionally  audible.  It  was  heard  best  immedi- 
ately the  child  awoke  in  the  morning,  and  was  then  distinctly  perceptible 
several  yards  from  her  cot.  During  the  child's  visit  to  me  no  cerebral  or 
other  murmui'  could  be  heard  with  the  stethoscope.  Still,  I  had  no  reason 
to  doubt  the  good  faith  of  the  relatives.  The  mother,  who  gave  me  the 
account,  told  her  tale  in  a  straightforward  manner,  with  the  air  of  one  who 
was  eager  to  receive  an  explanation  of  a  mystery  which  had  puzzled  her 
and  made  her  anxious. 

The  chief  cause  of  the  smallness  of  the  face  is  the  imperfect  develop- 
ment of  the  jaws.  Fleischmann  has  drawn  attention  to  the  angularity,  and 
flatness  anteriorly,  of  the  lower  jaw.  It  has  lost  its  normal  curve.  The.  in-- 
cisors  are  quite  in  a  straight  line  ;  then  at  the  situation  of  the  eye-teeth  the 
jaw  forms  a  sharp  angle  and  bends  abruptly  backwards.  This  is  due  to 
imperfect  growth  of  the  middle  portion  of  the  jaw.  Baginsky  describes  in 
addition  an  occasional  want  of  symmetry  between  the  two  halves  of  the 
bone,  which  gives  the  appearance  of  one  side  being  higher  than  the  other. 
The  efl"ect  of  this  delayed  development  of  the  jaw  upon  dentition  is  very 
important.  Eickety  children  are  late  in  teething.  At  whatever  age  be- 
fore the  completion  of  dentition  the  disease  may  begin,  directly  the  cranial 
or  facial  bones  become  affected  there  is  complete  arrest  in  dental  develop- 
ment. Thus,  if  the  disease  occurs  before  any  teeth  have  been  cut,  their 
appearance  may  be  indefinitely  delayed.  If  several  teeth  have  already 
pierced  the  gum  the  process  stops  there,  and  months  may  elapse  before 


BICKETS — SYMPTOMS.  139 

others  are  seen.  When,  however,  the  teeth  do  come  they  are  usually  cut 
without  much  trouble  ;  but  they  are  in  most  cases  of  bad  quahty  from  im- 
perfect development  of  the  dental  enamel,  and  quickly  blacken  and  decay. 

The  chest  is  deformed  in  a  very  characteristic  manner  on  account  of  the 
inability  of  the  softened  ribs  to  resist  the  pressure  of  the  atmosphere. 
Under  normal  conditions,  when  the  ribs  rise  and  the  chest  expands  in  the 
act  of  inspiration,  the  solid  framework  of  the  thorax  is  able  to  withstand 
the  pressure  of  the  expired  air,  and  the  chest  easily  enlarges  to  allow  of 
inflation  of  the  lungs.  Air  rushes  through  the  wind-pipe  to  dilate  the 
pulmonary  tissue  in  proportion  as  the  chest- walls  expand.  In  the  rickety 
chest,  on  the  contrary,  the  ribs  are  not  firm  but  yielding.  Consequently 
the  framework  of  the  thorax  is  not  rigid  enough  to  resist  the  pres- 
sure of  the  air  from  without,  aiid  when  the  effort  is  made  to  expand  the 
chest  the  softened  ribs  are  forced  in  at  the  sides — the  parts  where  they 
are  least  supported.  This  sinking  in  of  the  ribs  throws  the  sternum  for- 
wards. We  therefore  find  the  chest  grooved  laterally  and  the  breast-bone 
prominent  and  sharp.  The  groove  is  broad  and  shallow,  and  reaches  from 
the  second  or  third  rib  to  the  hypochondrium.  The  bottom  of  the  depres- 
sion is  formed  by  the  ribs  outside  their  junction  Avith  the  cartilages. 
Therefore  along  the  inner  side  of  the  groove  the  swollen  ends  of  the  ribs 
can  be  seen,  looking  like  a  row  of  large  beads  under  the  skin.  The  groove 
is  deepest  in  children  who  have  suffered  much  from  pulmonary  catan-h. 
In  such  subjects  the  impediment  to  the  entrance  of  air,  already  existing, 
is  increased  by  the  narrowing  in  the  calibre  of  the  smaller  tubes  induced 
by  the  derangement ;  and  the  softened  ribs  receive  still  less  support  from 
the  lung  tissue  beneath  them.  In  a  chest  so  deformed  each  inspiration 
increases  the  depth  of  the  lateral  groove,  and  at  the  same  time  produces  a 
deep  furrow  which  passes  horizontally  across  the  chest  at  the  level  of  the 
epigastrium.  This  furrowing  of  the  surface  has  been  shown  by  Sir  Wil- 
liam Jenner  to  be  due  not  to  the  traction  of  the  diaphragm,  as  was  taught 
by  Rokitansky,  but  like  the  lateral  grooves  of  the  chest  to  atmospheric 
pressure.  The  liver,  stomach,  and  spleen  support  the  parietes  under 
which  the}'  lie,  and  prevent  the  wall  at  these  points  from  falling  in. 

The  spine  is  often  bent.  In  an  infant  the  cervical  curve  is  increased 
so  that  the  head  is  sujDported  with  difficulty  and  falls  backwards  upon  the 
shoulders,  producing  a  very  characteristic  attitude.  Also,  the  weight  of 
the  head  and  shoulders,  as  the  child  sits  bending  forwards,  causes  a  pro- 
jection backwards  of  the  dorsal  and  lumbar  spines,  which  is  sometimes  so 
sharp  as  to  give  the  appearance  of  vertebral  caries.  The  deformity,  how- 
ever, subsides  completely  when  the  child  is  taken  up  under  the  arms  and 
the  spine  is  drawn  upon  by  the  weight  of  the  Hmbs  and  pelvis.  If  the  pa- 
tient is  able  to  walk,  there  is  an  increase  in  the  lumbar  and  dorsal  curves. 
The  curvature  may  be  lateral.  If  the  child  is  carried  habitually  on  his 
nurse's  left  arm,  the  trunk  sways  over  to  the  right ;  if  on  the  right  arm, 
the  body  leans  to  the  left.  In  all  these  cases  the  deformity  is  due  to  weak- 
ness of  the  ligaments  and  muscles. 

The  bones  forming  the  pelvis  may  be  also  deformed,  and  sometimes, 
like  the  chest,  are  greatly  distorted.  The  shape  assumed  by  this  frame- 
work is  very  various,  for  as  it  is  due  in  all  cases  to  compression  of  the 
yielding  bones,  it  will  be  determined  partly  by  the  age  at  which  the  dis- 
ease begins,  and  the  degree  to  which  ossification  has  advanced.  It  is 
therefore  different,  according  to  the  usual  attitude  of  the  child,  and  to  the 
circuij»stance  of  his  being  able  or  not  to  walk  about.  Its  most  ordinary 
sh'^jxa  >s  an  irregular  triangle.     Distortion  of  the  pelvis  is  of  great  impor- 


140  DISEASE  IN   CHILDKEIN'. 

tance  in.  its  in^uence  upon  ciiild-beariiig  in  the  adult  female  ;  but  even  in 
early  life  it  may  have  grave  consequences.  The  operation  of  lithotomy  in 
the  young  subject  has  been  attended  ^vitli  serious  difficulties,  and  even 
been  foUowed  by  fatal  results,  on  account  of  this  deformity. 

In  the  bones  of  the  limbs  the  articular  ends  are  nodular  from  eu' 
largement,  but  the  shafts  themselves  have  often  an  unnatural  shape.  In 
the  arm  the  humerus  is  often  curved  at  the  insertion  of  the  deltoid  muscle 
by  the  weight  of  the  forearm  and  hand  when  the  arm  is  raised.  The  ra- 
dius and  ulna  are  curved  outwards  and  twisted,  for  a  rickety  child  often 
rests  his  hands  on  the  bed  or  floor  to  assist  his  feeble  spine  in  supporting 
the  weight  of  his  trunk.  In  the  femur  the  head  of  the  bone  may  be  bent 
at  an  angle  with  the  shaft.  The  body  of  the  bone  is  curved  forwards  if 
the  child  cannot  walk  ;  for  as  he  sits  on  his  mother's  lap  the  weight  of  the 
leg  drags  upon  the  lower  part  of  the  thigh.  If  he  can  walk,  the  curve  is 
an  exaggeration  of  the  natural  curve — forwards  and  outwards.  The  tibia 
is  curved  outwards  if  the  child  is  unable  to  walk,  so  that  when  the  patient 
is  held  uj)right  the  knees  are  widely  apart.  The  deformity  is  due  in  this 
case  to  the  position  commonly  assumed  by  the  infant,  who  is  addicted  to 
sitting  cross-legged  on  his  bed,  so  as  to  make  pressure  upon  the  outside  of 
his  ankle.  In  children  who  can  walk  an  abrupt  ciu've,  having  its  convexity 
forwards  and  outwards,  is  seen  in  the  lower  third  of  the  bone.  The  lower 
limbs  are  not  distorted  in  the  infant  so  frequently  as  the  arms.  If  the 
child  cannot  stand,  these  extremities,  although  small  and  feeble,  are  often 
perfectly  straight.  In  cases  where  the  deformity  of  the  long  bones  is  ex- 
treme, the  shaft  is  not  only  bent  but  broken,  for  a  partial  ("green-stick") 
fractui'e  is  generall}^  present.  The  same  thing  is  often  seen  in  the  clavicles 
which  have  their  normal  cuiwes  very  greatly  exaggerated. 

Besides  the  softening  and  deformity  of  the  bones  there  is  another  con- 
sequence of  the  disease  which  is  of  great  importance.  This  is  the  arrest 
of  growth  and  development  of  bone  which  can  be  noticed  in  all  cases  oi 
severe  rickets.  Rickety  children  are  short  for  their  age,  and  remain  under- 
sized after  the  disease  has  passed  away.  The  arrest  of  growth  is  most 
marked  in  the  bones  of  the  jaws,  of  the  lower  limbs,  and  of  the  pelvis.  As 
it  affects  the  pelvis,  this  feature  is  of  especial  importance  on  account  of  its 
influence  upon  parturition  in  after  life  ;  for  if  the  cajjacity  of  the  pelvic 
fi'amework  be  not  only  diminished  by  distortion,  biit  also  relatively  small 
from  arrest  of  development  and  gTowth,  the  difiiculties  in  the  way  of  suc- 
cessful delivery  may  be  insuperable. 

The  weakness  in  the  lower  limbs,  which  is  a  marked  feature  in  rickets, 
is  due  not  alone  to  feebleness  of  the  muscles  combined  with  the  general 
debility  of  the  child.  There  is  also  great  weakness  and  looseness  of  the 
Hgaments  of  the  joints.  This  weakness  is  more  pronounced  in  cases  where 
the  disease  begins  after  the  end  of  the  second  year.  In  such  cases  of  late 
rickets  softening  and  deformity  of  bone  are  less  common  features  of  the 
disease,  while  the  looseness  of  the  joints  from  marked  relaxation  of  the 
ligaments  may  reach  a  very  high  degree.  In  such  cases,  too,  the  disease 
having  begun  after  the  completion  of  dentition,  the  teeth  are  often  white 
and  sound. 

During  the  progress  of  the  bone-changes  which  have  been  described, 
the  general  symptoms  continue  and  become  more  severe.  The  head  per-, 
spirations  are  profuse  ;  the  child  can  hardly  be  kept  covered  in  his  bed, 
but  whether  it  be  night  or  day  pushes  off  the  bed-clothes  and  exposes  hi& 
naked  limbs  to  the  air.  In  bad  cases  his  tenderness  and  dislike  to  move- 
ment are  extreme.     So  long  as  he  is  left  alone  he  is  patient  and  still,  but 


EICKETS — SYMPTOMS.  141 

when  approached  or  noticed  he  at  once  becomes  fretful  and  apprehensive 
of  distui'bance.  He  wiU  sit  for  hours  together,  heedless  of  his  toys, 
crouched  u^^  in  his  cot ;  his  legs  doubled  beneath  him,  his  spine  bowed, 
and  his  head  thrown  back  ;  supporting  his  body  upon  his  hands  placed  be- 
fore him  on  the  bed.  On  account  of  the  softened  ribs  and  his  consequent 
difficulty  in  expanding  the  lungs,  his  breathing  is  rajDid,  and  his  whole  at- 
tention seems  concentrated  upon  the  efficient  discharge  of  this  function. 
His  appetite  varies.  Sometimes  it  is  poor,  but  more  often  it  is  good  and 
may  be  ravenous.  If  attention  has  not  been  paid  to  his  diet,  and  the  child 
continues  to  pass  large  quantities  of  jDale,  putty-like  matter,  he  will  usually 
swallow  almost  anything  that  is  given  to  him.  Sickness  is  not  common, 
and  severe  diarrhoea  is  only  occasionally  met  with  ;  but  moderate  attacks  of 
purging  are  frequently  seen,  the  stools  being  green,  slimy,  and  oifensive. 

The  belly  in  rickety  children  is  always  large,  even  in  cases  where  no  dis- 
ease of  the  liver  or  sjDleen  can  be  detected.  The  swelling  is  principally  due 
to  feebleness  of  the  muscular  walls,  allowing  of  accumulation  of  flatus,  and  to 
the  shallowness  of  the  pelvis,  which  throws  all  the  abdominal  viscera  above 
the  level  of  the  pelvic  brim.  If  the  spleen  is  very  large  it  may  cause  a 
special  swelling  on  the  left  side  of  the  belly,  sometimes  reaching  below  the 
umbihcus.  It  may  be  remarked  here  that  in  cases  where  the  liver  and 
spleen  can  be  felt  below  the  level  of  the  ribs  we  must  not  at  once  conclude 
that  their  size  is  abnormal.  The  organs  may  be  merely  pushed  down  by 
the  depression  of  the  diaphragm  and  diminished  capacity  of  the  thorax. 
Therefore,  after  ascertaining  the  position  of  the  lower  edge  the  upper 
limit  of  the  organs  should  be  estimated  by  careful  percussion.  In  addition 
to  enlargement  of  the  liver  and  spleen  the  superficial  lymphatic  glands  are 
sometimes  swollen,  and  can  be  distinctly  felt  larger  than  natural  in  the 
axillae  and  groins. 

Kickets  is  not  a  cause  of  pyrexia.  If  the  temperature  rise  above  the 
normal  level  a  complication  may  be  at  once  suspected.  If  fever  occur 
dui'ing  the  stage  of  imx3rovement  it  often  announces  the  return  of  denti- 
tion, and  shows  that  a  tooth  is  pressing  through  the  gum.  The  degree  of 
wasting  varies.  If  the  disease  be  mild  the  child,  although  pale,  is  often 
exceptionally  plump  from  over-nourishment  of  the  subcutaneous  fat ;  but 
unless  recovery  take  place  shortly  the  Hmbs  quickly  begin  to  feel  soft,  and 
soon  the  child  can  be  seen  to  be  evidently  wasting.  The  complexion  is 
always  pale,  the  lower  eyelid  is  frequently  discoloured,  and  the  borders 
of  the  mouth  have  a  bluish  tint.  If  great  enlargement  of  spleen  be  pres- 
ent the  tint  of  the  face  becomes  peculiarly  bloodless  and  the  mucous 
membranes  are  very  pale.  Kickety  children  are  backward  in  every  way, 
both  in  mind  and  body.  Their  intellect  seems  to  grow  as  slowly  as  their 
bones.  On  account  of  their  inability  to  join  in  ordinary  childish  games 
they  are  much  in  the  society  of  older  persons,  and  therefore  acquire  an 
unchildish  way  of  expressing  themselves  ;  but  they  talk  very  late  and  are 
dull  at  picking  up  new  words  and  phrases. 

The  progress  of  the  disease  is  slow,  and  unless  the  insanitarj^  condi- 
tions which  have  led  to  it  be  removed,  it  goes  on  fi'om  bad  to  worse. 
These  children  often  die  from  some  catarrhal  comphcation.  A  bad  diarrhoea 
is  very  dangerous  on  account  of  their  general  weakness,  and  a  compara- 
tively mild  pulmonary  catarrh  may  prove  fatal  through  the  softening  of 
the  ribs.  Death  rarely  takes  place  from  the  intensity  of  the  general  dis- 
ease. When  improvement  begins  under  judicious  treatment,  the  general 
tenderness  is  usually  the  first  symptom  to  subside.  The  child  is  less  fret- 
ful when  noticed  and  takes  more  interest  in  what  passes  around  his  bed. 


142  DISEASE   IN   CHILDEElSr. 

At  the  same  time  the  softening  of  the  bones  diminishes,  and  as  the  ribs, 
regain  their  firmness  the  marked  improvement  in  breathing  which  results 
from  the  greater  rigidity  of  the  chest-wall  cannot  escape  notice.  Teething 
also  begins  again  ;  the  wasting  ceases  ;  the  belly  is  less  distended  ;  the 
sweats  diminish  and  all  the  symptoms  undergo  great  improvement.  These 
childi'en  often  become  very  sturdy  and  strong,  but  usually  remain  short  in 
stature  even  when  their  full  growth  has  been  attained. 

A  form  of  the  disease  has  been  described  which  has  been  called  "acutt^ 
rickets."  In  this  variety  the  articular  ends  of  the  long  bones  undergo 
rapid  enlargement  and  become  tender  on  pressure.  Secondary  cylindrical 
swellings  are  also  seen  about  the  hmbs.  The  temperature  is  high.  It 
seems  probable,  from  the  investigations  of  Drs.  Cheadle  and  Barlow,  that 
these  cases  are  instances  of  scurvy  grafted  on  to  rickets.  They  are  referred 
to  more  fully  in  the  chapter  treating  of  the  former  disease. 

Complications. — It  is  not  often  that  a  case  of  rickets  remains  uncompli- 
cated by  some  intercurrent  complaint.  The  subject  of  a  pronounced  form 
of  rickets  has  but  little  resisting  power,  and  is  readily  affected  by  any  kind 
of  injurious  influence.  But  he  is  in  addition  peculiarly  liable  to  certain 
forms  of  derangement  on  account  of  the  special  tendencies  of  this  phase  of 
nial-nutrition.  The  sensitiveness  to  chills  manifested  by  a  rickety  child 
has  been  already  remarked  upon.  This  proneness  to  catarrh  may  be  the 
consequence  of  the  profuse  and  ready  action  of  the  sweat-glands,  and  it  is 
no  doubt  encouraged  by  the  child's  practice,  when  his  perspirations  begin, 
of  throwing  off  the  coverings  of  his  bed.  The  various  forms  of  catarrh  are 
therefore  especially  liable  to  occur,  and  pulmonary  and  intestinal  catarrhs 
are  the  most  frequent  of  these  derangements.  Few  rickety  children  are 
without  a  cough,  and  this  symptom,  on  account  of  the  unnatural  flexibihty 
of  their  chest-walls,  must  be  always  regarded  mth  anxiety.  The  danger  of 
even  a  mild  pulmonary  catarrh  in  these  j)atients,  and  the  readiness  with 
which  this  derangement  gives  rise  to  collapse  of  the  lung,  is  referred  to 
elsewhere  (see  p.  467).  To  this  cause  a  large  proportion  of  deaths  is 
due.  Again,  more  or  less  intestinal  catarrh  is  a  common  derangement  in 
this  disease,  and  after  any  unusual  exposure  the  looseness  of  the  bowels 
may  pass  into  a  severe  attack  of  purging.  Diarrhoea,  on  account  of  the 
great  general  weakness,  is  a  source  of  extreme  danger,  and  during  the 
changeable  seasons  of  the  year  many  children  are  carried  off  by  this  com- 
plaint. 

Another  peculiarity  of  the  rickety  state  is  the  curious  impressibility 
of  the  nervous  system  which  manifests  itself  by  the  ready  occurrence  of 
various  forms  of  spasm.  Reflex  convulsions  are  common,  and  laryngismus 
stridulus  is  practically  confined  to  the  subjects  of  rickets.  Catarrh  of  the 
larynx  is  also  liable  to  be  accompanied  by  spasm,  and  therefore  catarrhal 
croup  (laryngitis  stridulosa),  as  is  elsewhere  stated,  is  a  frequent  cause  of 
anxiety.  These  subjects  need  not  be  further  referred  to  in  this  place,  as 
they  all  receive  consideration  in  special  chapters. 

One  other  not  uncommon  complication  is  chronic  hydrocej^halus.  On 
account  of  the  small  size  of  the  brain  in  many  cases  of  rickets,  fluid  is 
effused  into  the  cranial  cavity  to  fill  up  the  resulting  space.  The  amount 
of  serosity  is,  however,  seldom  large  and  rarely  comes  to  be  a  source  of 
danger. 

An  occasional  complication,  although  not  a  common  one,  is  acute  tuber- 
culosis. The  disease  is  probably  in  all  cases  the  result  of  an  acquired  ten- 
dency due  to  the  presence  in  the  body  of  a  softening  cheesy  deposit.  It 
certainly  is  proportionately  less  frequent  in  rickety  subjects  than  in  children 


IlICKETS — COMPLICATIONS — DIAGNOSIS — PEOGNOSIS.         143 

free  from  this  disorder  of  nutrition  ;  but  it  is  necessary  to  be  aware  that 
rickets  does  not  exclude  tuberculosis. 

Diagnosis. — In  a  mild  case  of  rickets  the  prominent  features  are  the 
swelling  of  the  epiphyseal  ends  of  the  long  bones,  the  tardy  eruption  of 
the  teeth,  and  the  backwardness  in  learning  to  walk.  If  we  notice  the 
wrists  to  be  large  in  a  young  child,  we  should  at  once  count  the  number 
of  his  teeth  and  ask  if  he  is  able  to  stand  alone.  If  a  child  ten  months 
old  shows  no  sign  of  a  tooth,  if  his  wrists  are  large,  and  if  when  held  upon 
his  feet  his  limbs  double  up  helplessly  beneath  him,  there  can  be  little 
doubt  that  he  is  the  subject  of  rickets.  Even  before  the  swelling  of  the 
articular  ends  of  the  bones  has  come  on  the  onset  of  the  disease  may  be 
suspected.  Big,  fat,  flabby  infants  are  generally  slightly  rickety,  and  if 
a  child  sweats  profusely  about  the  head,  aud  is  kept  covered  at  night  only 
with  great  difficulty,  we  can  have  little  doubt  that  the  characteristic  signs 
of  rickets  are  about  to  appear.  In  such  a  case  attention  should  be  at  once 
directed  to  the  child's  diet,  the  i-egularity  with  which  he  is  taken  out  of 
doors,  and  the  state  as  to  ventilation  of  his  sleeping-room,  so  that  any 
errors  in  management  may  be  promptly  corrected. 

In  a  marked  case  of  rickets  the  deformity  of  the  chest,  the  bending 
of  the  bones,  the  enlargement  of  the  joints  and  beading  of  the  ribs  are 
sufficiently  characteristic.  Even  the  position  of  the  patient  as  he  sits  with 
his  legs  crossed  and  his  head  fallen  back  between  his  shoulders,  supporting 
his  feeble  spine  by  his  hands  placed  before  him  on  the  floor,  enables  us  at 
once  to  recognize  the  case  as  one  of  well-defined  rickets. 

The  complete  uselessness  of  the  lower  limbs  in  many  of  these  cases  is 
often  a  serious  anxiety  even  to  parents  who  regard  the  other  symptoms 
with  comparative  indifference,  for  they  fear  lest  the  child  should  be  "going 
to  be  paralysed."  But  although  the  patient  has  no  idea  of  even  placing 
his  feet  upon  the  ground,  and  cries  bitterly  when  any  attempt  is  made  to 
persuade  him  to  do  so,  power  of  movement  of  the  legs  is  unimpaired. 
If  the  skin  of  the  legs  be  pinched  or  gently  pricked  he  at  once  draws  his 
limbs  out  of  the  way.  Of  other  local  symptoms  : — The  nature  of  the  an- 
tero-posterior  spinal  curvature  is  readily  shown  by  lifting  the  child  up 
under  the  arms,  when  the  weight  of  the  pelvis  and  legs  at  once  causes  the 
spinal  distortion  to  disappear.  A  lateral  curvature  is  distinguished  from 
the  effects  of  pleurisy  by  noting  the  presence  of  signs  of  rickets  and  the 
absence  of  those  of  effiisiou  into  the  chest  cavity.  The  rickety  head  differs 
from  a  skull  dilated  by  excess  of  fluid  by  its  shape.  Instead  of  being  glob- 
ular it  is  elongated  from  before  backwards,  with  a  characteristic  squareness 
of  the  forehead,  and  moreover  this  shape  of  head  is  associated  with  other 
well  marked  signs  of  rickets.  The  fontanelle  does  not  always  furnish 
trustworthy  evidence  ;  for  although  often  depressed  in  rickets  and  raised 
in  hydrocephalus,  these  conditions  may  be  reversed.  Certainly  a  depressed 
fontanelle  is  compatible  with  a  fairly  copious  effusion  of  intra-cranial 
fluid. 

In  the  present  state  of  our  knowledge  no  differential  diagnosis  can  be 
made,  during  life  at  any  rate,  between  rickets  and  osteo-malacia.  Cases 
where  softening  and  deformity  of  bone  are  pi-esent  must  be  assumed  to  be 
rickets.  Fortunately,  for  all  practical  pui-poses,  a  distinction  in  any  indi- 
vidual case  is  unnecessary,  as  the  measures  to  be  adopted  for  the  relief  of 
the  patient  are  the  same  whatever  be  the  correct  pathology  of  the  osseous 
lesions. 

Pro^nosis.^Kickets  is  not  a  fatal  disease  in  itseK  unless  the  bony  change 
be  far  advanced,  nor  even  in  such  a  case  does  death  often  ensue  except  as  a 


144  DISEASE   IlSr   CHILDEEN. 

consequence  of  some  catarrhal  complication.  As  a  rule,  improvement  be- 
gins directly  measures  are  taken  to  amend  the  unwholesome  conditions  in 
which  the  patient  is  li\dng.  The  dangers  of  pulmonary  catarrh  and  atelec- 
tasis in  a  child  with  great  deformity  of  chest  are  elsewhere  referred  to  ; 
and  the  serious  consequences  which  may  result  from  diarrhoea  in  an  infant 
reduced  to  a  state  of  serious  weakness  by  chronic  mal-nutrition  need  not 
be  insisted  upon.  Of  the  nervous  complications,  laryngismus  stridulus  is 
sometimes  a  cause  of  sudden  death,  but  reflex  convulsions  excited  by  some 
trifling  irritant  rarely  have  any  ill  results. 

Enlargement  of  the  spleen,  liver,  and  lymphatic  glands  generally  is 
very  rare,  but  if  jDresent  should  excite  great  anxiety.  It  is  more  common 
to  find  enlargement  of  the  spleen  alone  without  any  affection  of  other  in- 
ternal organs.  In  rickets,  as  has  been  said,  the  spleen  is  often  the  seat  of 
simple  hyperplasia.  This  lesion,  as  it  is  an  additional  cause  of  anaemia, 
no  doubt  introduces  into  the  case  a  further  element  of  danger,  but  the 
danger  is  dependent  more  upon  the  intensity  of  the  rickety  process  than 
uj)on  the  degree  of  splenic  swelling.  If  the  sjanptoms  of  rickets  are  com- 
paratively mild,  and  due  care  be  taken  to  shield  the  child  from  catarrhal 
complications,  the  presence  of  a  big  spleen  does  not  indicate  the  probabil- 
ity of  a  fatal  termination  to  the  illness. 

Age  has  no  influence  upon  the  prognosis  of  rickets,  and  when  the 
disease  occurs  as  a  sequel  of  inherited  syphihs,  it  presents  no  special  diffi- 
culties in  its  treatment. 

With  regard  to  the  permanence  of  the  unsightly  deformities  of  bone, 
it  is  often  astonishing  to  note  the  improvement  which  takes  place  after 
recovery  from  rickets  in  the  deformities  which  seemed  the  most  unhkely 
to  be  reduced.  Large  joints  grow  smaller,  crooked  bones  become  almost 
straight,  and  a  distorted  chest  will  recover  itself  in  a  surprising  manner. 
In  some  children,  however,  improvement  goes  on  farther  than  it  does  in 
others,  and  therefore,  while  encouraging  the  parents  to  believe  that  there 
will  be  considerable  improvement,  we  must  not  be  too  sanguine  as  to  the 
complete  disappearance  of  all  disfigurement. 

Treatment — In  every  case  of  rickets  our  first  care  should  be  not  to  give 
cod-liver  oil  or  tonics,  but  to  inquire  into  the  conditions  in  which  the  child 
is  hving  ;  to  ask  about  the  food  he  is  taking,  the  quantity  allowed  for  each 
meal,  the  frequency  with  which  the  meals  are  repeated,  and  the  degree  of 
cleanliness  of  the  feeding  apparatus.  We  should  then  turn  to  the  subject 
of  his  clothing,  the  ventilation  of  his  bedroom,  and  the  number  of  hours 
he  is  passing  out  of  doors.  The  real  treatment  consists  in  attention  to  all 
these  important  matters,  and  not  solely  in  the  administration  of  any  par- 
ticular drug.  Medicines  are  no  doubt  useful  as  helps  in  the  treatment, 
but  their  importance  is  trifling  as  compared  with  that  of  a  reformation  of 
the  unwholesome  conditions  under  which  the  failure  in  nutrition  has  taken 
place.  The  reader  is  referred  to  the  chapter  on  the  treatment  of  infantile 
atrophy  for  general  directions  with  regard  to  the  feeding  and  management 
of  young  children. 

Almost  all  cases  of  rickets  have  been  preceded  by  symptoms  of  diges- 
tive derangement  or  bowel  complaint,  and  unless  improvement  has  already 
begun  we  often  find  signs  of  looseness  or  intestinal  derangement  still  per- 
sisting. This  should  at  once  be  remedied.  The  belly  should  be  kept 
warm  with  an  ample  flannel  binder,  and  the  child  should  take  a  drop  of 
laudanum  to  control  the  undue  peristaltic  action  of  the  bowels,  with  a  few 
grains  of  the  bicarbonate  of  soda  to  correct  acidity,  in  an  aromatic  water 
sweetened  with  a  few  drops  of  spirits  of  chloroform  three  times  a  day.     In 


EICKETS — PEOGNOSIS — TREATMENT.  145 

many  cases  there  is  .a  special  difficulty  in  digesting  starch.  In  almost  all 
instances  we  find  that  this  variety  of  food  has  been  given  in  great  excess. 
The  quantity  must  be  therefore  considerably  reduced,  and  that  taken 
should  be  guarded  with  malt,  as  in  Mellin's  food.  Hoff 's  extract  of  malt,  in 
doses  of  two  or  three  teaspoonfuls  three  times  a  day,  is  of  great  service  in 
these  cases.  If  the  child  be  no  longer  an  infant,  the  diet  should  be  arranged 
as  directed  under  the  heading  of  "  Chronic  Diarrhoea  "  (see  page  640). 

Plenty  of  fresh  air  should  be  insisted  upon.  The  child,  warmly  clad, 
should  be  sent  out  in  all  suitable  weathers,  and  if  care  be  taken  that  his 
feet  are  weU  warmed  before  he  leaves  the  house,  there  will  be  little  danger 
of  his  catching  cold.  If  the  patient  have  reached  the  age  of  eight  or  ten 
months  he  should  be  carefully  packed  with  cushions  in  a  perambulator, 
and  in  cold  weather  should  always  have  a  hot  bottle  to  his  feet  while  out 
of  doors.  The  ventilation  of  his  sleeping-room  must  be  attended  to.  A 
small  fire  ia  the  winter,  and  a  lamp  placed  in  the  fender  during  the  sum- 
mer months,  will  insure  a  sufficient  circulation  of  air  through  the  bed- 
chamber. Both  the  patient  and  his  immediate  surroundings  must  be  kept 
scrupulously  clean.  Every  morning  the  whole  body  should  receive  a  thor- 
ough washing  with  soap  and  water,  and  be  well  sjjonged  in  the  evening 
before  the  child  is  put  into  his  cot.  On  account  of  the  copious  perspira- 
tions his  body  linen,  as  well  as  that  belonging  to  his  cot,  soon  becomes 
saturated  with  moisture.  His  underclothing  should  therefore  be  changed 
as  often  as  is  necessary.  Every  morning,  too,  his  mattress  and  bed-cov- 
erings must  be  thoroughly  exposed  to  the  au\  The  sheets  also  should 
be  changed  frequently  and  be  carefully  aired. 

If  i;he  above  measures  are  properly  attended  to  improvement  will  quickly 
begin.  Directly  the  bowels  have  been  got  into  a  healthy  state  cod-hver  oil 
should  be  given.  A  quantity  much  less  than  that  usually  prescribed  is, 
however,  sufficient ;  for  children,  infants  especially,  have  comparatively 
small  power  of  digesting  fats.  It  is  best  to  begin  with  ten  drops  of  the 
light  brown  oil,  and  during  its  administration  the  stools  must  be  carefully 
watched  for  any  appearance  of  undigested  oil.  The  quantity  can  be  grad- 
ually increased  by  a  few  drops  at  a  time  as  long  as  none  of  the  oil  is  seen 
to  pass  undigested  from  the  bowels.  Iron  is  also  useful.  Iron  wine 
(lU  xx.-xL),  the  exsiccated  sulphate  of  iron  (gr.  ij.-iv.),  or  the  tincture  of  the 
perchloride  (lU  v.-xv.) — all  these  are  useful,  and  are  to  be  preferred  to  any. 
of  the  syrupy  preparations.  The  latter  are  not  fitted  for  rickety  subjects, 
as_  the  large  quantity  of  sugar  they  contain  encourages  fermentation  and 
acidity,  and  often,  indeed,  by  the  disturbance  it  sets  up  in  the  bowels,' 
makes  each  dose  of  the  medicine  decidedly  prejudicial  to  the  patient.  If 
quinine  be  given,  the  tannate  is  the  most  suitable  preparation.  One  or  two- 
grains  should  be  suspended  in  glycerine  and  given  two  or  three  times  a 
day.  If  there  is_  any  tendency  to  acidity  left  after  rearrangement  of  the 
diet,  the  ammonio-citrate  of  iron  may  be  given  in  a  draught  with  a  few 
grains  of  bicarbonate  of  soda  and  one  drop  of  the  tincture  of  nux  vomica, 
between  meals. 

The  salts  of  lime  were  at  one  time  recommended  in  the  treatment  of 
rickets,  as  it  was  supposed  that  the  bone-softening  was  due  to  a  deficiency 
of  lime  in  the  system.  In  practice,  however,  the  use  of  these  drugs  has 
not  been  found  of  value  ;  indeed,  the  remedy,  for  any  special  benefit  it 
produces,  may  as  well  not  be  given  at  all. 

The  copious  perspirations  from  the  head  and  neck  are  always  a  source 
of  great  anxiety  to  the  mother.    They  can  be  controlled  by  applying  bella- 
donna liniment  to  the  parts  where  secretion  is  copious  before  the  child 
10 


146  DISEASE   IIST   CHILDEElSr. 

is  put  to  bed.  He  may  also  take  one  drop  of  liq.  atroj)iae  every  night. 
Dii-ectly  the  tenderness  has  subsided  steady  frictions  with  the  hand  alone, 
or  with  olive-oil,  all  over  the  body,  especially  along  the  spine,  are  of  great 
service  and  do  much  to  strengthen  the  muscles.  The  nui'se  should  be  di- 
rected to  rub  the  child  steadily  for  a  cjuarter  of  an  hoiu-  immediately  after 
his  bath.  In  the  morning  the  open  hand  or  a  flesh  glove  may  be  used  ;  in 
the  evening  it  is  advisable  to  employ  warm  ohve-oil  for  the  frictions.  As 
the  child  improves  and  his  strength  begins  to  return,  a  cold  or  tepid  saline 
douche,  given  as  he  sits  in  the  wann  water  of  his  bath,  viill  be  of  sei-vice. 

Care  must  be  taken  to  j)i"event  the  child's  getting  on  his  feet  before 
his  bones  are  sufficiently  sohd  to  bear  his  weight.  As  his  strength  im- 
proves he  seizes  every  opportunity  of  practising  his  newly  accjuired  power 
of  standing,  and  very  mai'ked  deformities  of  the  tibia  may  be  jDroduced  by 
this  means.  In  such  cases  support  may  be  given  to  the  limbs  by  the  use 
of  light,  padded  splints,  and  if  the  ligaments  of  the  joints  are  much  relaxed 
a  firmly  apphed  elastic  bandage  can  be  made  use  of. 

The  treatment  of  any  deformities  which  may  remain  after  the  complete 
cessation  of  the  disease  faUs  rather  under  the  depariment  of  the  surgeon. 
For  the  treatment  of  the  various  comphcations  of  rickets  the  reader  is 
referred  to  the  special  chapters  treating  on  these  subjects. 


CHAPTER  11. 

AGUE. 

Childken  who  live  in  malarious  districts  are  not  exempt  from  ague ;  indeed, 
in  early  life  the  system  is  said  to  be  particularly  susceptible  to  the  action 
of  the  malarious  poison.  During  infancy  and  up  to  the  age  of  five  or  six 
years,  the  fever  may  assume  peculiar  characters,  and  unless  detected  early, 
and  promptly  treated,  may  even  prove  fatal.  In  more  advanced  childhood 
the  symptoms  present  little  variety  from  those  met  with  in  adult  life. 

Causation. — Ague  is  an  endemic  disease,  which  is  excited  by  residence 
in  a  malarious  neighbourhood.  An  ague-breeding  district  is  usually  low- 
lying,  marshy  or  ill-drained,  and  has  a  more  or  less  porous  soil,  composed 
largely  of  rotting  vegetable  matter.  Still,  these  conditions  are  not  always 
found  united  in  places  where  ague  abounds .  A  disintegrated  rocky  soil,  which 
is  very  porous,  and  is  saturated  with  water  to  within  a  few  inches  of  the  sur- 
face, may  largely  generate  the  malarious  poison,  although  decaying  vege- 
table matter  is  entirely  absent.  A  soil  thus  deleterious  is  i-endered  doubly 
noxious  by  digging  below  the  surface.  Indeed,  in  some  cases  a  spot  previ- 
ously healthy  has  been  known  to  become  malarious  after  disturbance  of 
the  soil  for  building  or  other  purposes.  Even  a  malarious  district  is  only 
poisonous  at  certain  seasons.  In  temperate  climates  the  sj^ring  and  au- 
tumn are  the  agueish  periods  of  the  year.  In  the  tropics  the  miasma  is 
evolved  in  the  dry  hot  season  which  succeeds  to  the  j^eriodic  rains.  The 
malaria  is  thrown  out  from  the  soil,  especially  at  night-time,  and  rises  to  a 
certain  distance  from  the  ground.  It  is  always  more  intense  near  the  sur- 
face, being  apparently  more  diluted  or  rarified  as  the  distance  from  the 
earth  increases.  It  may  be  carried  by  the  wind  to  a  considerable  distance 
from  the  spot  where  it  has  been  generated,  but  appears  to  be  incapable  of 
passing  a  broad  sheet  of  water,  and  even  a  band  of  trees  is  found  to  arrest 
the  progress  of  the  miasma. 

Amongst  the  residents  of  a  malarious  neighbourhood  the  disease  is 
very  common.  The  children  living  in  the  district  are  said  rarely  to  escape  ; 
for  even  if  considered  healthy  they  mil  be  found,  according  to  Steiner,  to 
have  the  spleen  enlarged.  Even  the  new-born  infants  of  mothers  who  suf- 
fer from  intermittent  fever  may  be  found  at  birth  to  present  the  enlarged 
spleen,  the  bronzed  skin,  and  all  the  other  signs  of  a  pronounced  malari- 
ous cachexia.  It  has  even  been  affirmed  that  the  milk  of  a  cachectic  wo- 
man is  capable  of  communicating  the  disease  ;  but  this  statement  requires 
further  proof. 

Morbid  Anatomy. — When  children  who  have  been  subject  to  ague  die, 
the  only  constant  lesion  discovered  is  an  enlargement  of  the  spleen.  Dui'- 
ing  an  acute  attack,  and  for  some  time  afterwards,  the  organ  is  engorged 
with  blood  so  as  to  be  several  times  its  natural  size.  It  afterwards  dimin- 
ishes in  bulk  ;  but  if  the  child  remain  in  the  malarious  district  it  contin- 
ues to  be  harder  and  larger  than  natural     The  cut  surface  is  then  pale 


148  DISEASE  IK   CHILDEEN". 

and  dryisli,  witli  white  strife  from  thickened  trabeculpe,  and  sometimes  it 
lias  a  gray  tint  or  even  a  speckled  appearance  from  dark  gray  spots.  Tlie 
capsule  is  thickened  and  often  adherent.  Besides  the  spleen,  the  liver  is 
also  congested  during  an  acute  attack,  and  afterwards  may  remain  more  or 
less  enlarged. 

Symptoms. — In  early  life  ague  may  occiTr  either  in  the  intermittent  or 
remittent  form.  Both  are  common  ;  for  although  in  the  adult  the  remit- 
tent form  is  rarely  seen,  except  in  the  more  serious  variety  of  the  disease, 
which  occurs  in  tropical  climates,  in  the  young  child  a  comjjaratively  fee- 
ble dose  of  the  jDoison  may  produce  a  profound  efi'ect  uj)on  the  constitu- 
tion, and  excite  fever  of  the  remittent  t}^e  even  in  a  temperate  zone.  La 
most  cases  the  fever  is  quotidian,  but  it  may  be  tertian  and  even,  although 
rarely,  quartan.  The  three  stages  of  the  attack  are  usually  to  be  recog- 
nised ;  but  they  are  less  perfectly  marked  than  in  the  adult,  and  are  often 
characterised  by  peculiar  features  not  found  in  after-life. 

As  often  happens  in  the  case  of  the  adult,  the  attack  may  not  come  on 
for  some  considerable  time  after  exposure  to  the  malarious  influence.  In- 
deed, cases  are  sometimes  met  with  in  which  a  child,  who  is  free  from  fever 
while  he  lives  in  the  agueish  district,  only  begins  to  suffer  after  he  is  re- 
moved to  a  more  healthy  situation. 

The  cold  stage  may  begin  with  very  violent  symptoms  or  may  give 
only  trifling  indications  of  its  presence.  The  child  may  have  a  severe  rigour 
Hke  an  adult,  or  may  be  taken  suddenly  with  a  convulsive  seizure.  If  the 
latter  the  fit  is  rarely  repeated,  but  is  followed  almost  immediately  by 
heat  of  skin  and  all  the  symptoms  of  the  second  stage.  In  infants  neither 
rigours  nor  convulsions  may  be  seen.  Instead,  the  baby  seems  drowsy ; 
frequently  ya'wns ;  sometimes  stretches  itself ;  is  peevish  and  fretful,  re- 
fusing the  bottle  ;  and  looks  j^ale  and  prostrate,  with  perhaps  some  lividity 
of  the  lips  and  finger-nails.  In  rare  cases  the  hands  and  feet  are  cold  to 
the  touch.  This  stage  is  usually  short.  The  tempej'ature  rises  progres- 
sively throughout,  and  even  at  the  beginning,  when  the  child  feels  cold  or 
actually  shivers,  is  above  the  normal  level.  Towards  the  end  of  the  stage 
the  mercury  may  register  between  103  and  104  degTees  of  heat. 

The  hot  stage  is  usually  better  marked.  In  this  the  skin  is  distinctly 
febrile  ;  the  child  is  drowsy  and  looks  ill ;  if  not  flushed,  the  face  is  pinched 
and  pale  ;  and  the  head  is  said  to  be  tender.  The  tongue  is  covered  with 
a  yellowish  fur,  and  according  to  Dr.  Fruitnight  it  is  not  uncommon  for  the 
throat  to  be  congested  with  a  whitish  deposit  on  the  tonsils.  The  child 
is  usually  thirsty  and  drinks  greedily  ;  he  often  coughs — indeed,  a  cough  is 
said  by  Dr.  Fruitnight  to  be  a  constant  symptom  of  the  attack  ;  the  pulse 
is  rapid,  feeble,  and  compressible.  Pressure  on  the  liver  and  sjDleen  elicits 
signs  of  discomfort,  and  both  these  organs  on  paljDation  are  found  to.  be 
enlarged.  The  child  often  vomits,  sometimes  bringing  up  bile  ;  and  the 
bowels  may  be  relaxed.  Occasionally  an  icteric  tinge  is  noticed  on  the 
skin.  There  is  one  symptom  sometimes  met  with  in  a  marked  case  which 
must  not  be  omitted.  This  is  a  general  bright  redness  of  the  surface.  Such 
a  rash,  accompanied  by  a  high  temj^erature,  and  following  rapidly  upon  a 
rigour  or  an  attack  of  convulsions,  would  strongly  suggest  scarlatina,  espe- 
cially if  at  the  same  time  some  redness  of  the  thi'oat  could  be  detected. 
Through  this  stage  the  temperature  continues  to  rise  progressively,  and 
towards  the  end  has  reached  its  maximum,  which  may  be  105°  or  higher. 

The  third  or  sweating  stage  is  very  imperfectly  developed  in  the  infant. 
Older  children  may  burst  out  into  a  profuse  perspiration  like  the  adult. 
StUlj  .whether  the  disease  end  in  sweating  or  not,  there  is  a  remarkable 


AGUE — SYMPTOMS — DIAGNOSIS.  149 

fall  of  temperature  at  the  end  of  the  hot  stage,  and  the  thermometer  will 
often  mark  100°  or  101°  where  a  very  short  time  before  the  pyrexia  had 
been  as  high  as  106°  or  107°.  At  the  same  time  that  this  diminution  in 
the  bodily  heat  is  noticed  there  is  usually  a  profuse  secretion  from  the 
kidneys,  and  the  child  passes  a  large  quantity  of  limpid  urine.  According 
to  Dr.  Gee's  observations,  the  proportion  of  urea  and  chloride  of  sodium 
are  greatly  increased  during  the  hot  stage,  while  the  phosphates  are 
diminished.  As  the  temperature  falls  the  amount  of  urea  and  of  chloride 
of  sodium  diminish,  while  the  proportion  of  phosphates  is  augmented. 

The  duration  of  the  attack  varies.  The  hot  stage,  which  lasts  the 
longest,  may  occupy  six  or  eight  hours.  After  the  attack  is  over,  the  child, 
if  he  is  suffering  from  the  intermittent  form  of  the  disease,  seems  quite 
well  until  the  next  attack  begins.  If  the  fever  is  of  the  remittent  type,  the 
patient  remains  more  or  less  feverish  in  the  interval.  He  is  thirsty,  has 
little  appetite,  is  languid,  peevish,  and  restless  ;  looks  pinched  and  ill,  and 
usually  loses  flesh.  The  wasting  is  sometimes  increased  by  a  troublesome 
diarrhoea.  Often  the  fever,  at  first  intermittent,  may  pass  into  the  remit- 
tent form  ;  and  then,  again,  in  its  progress  towards  recovery  return  to  the 
intermittent  type.  In  many  cases  of  the  remittent  form  of  the  disease  the 
fever  runs  a  less  acute  course,  and  the  temperature,  although  persistently 
elevated,  does  not  reach  the  high  level  common  in  the  shorter  and  sharper 
attacks.  Thus  during  the  paroxysms  it  may  rise  no  higher  than  102°  or 
103°,  and  during  the  remissions  may  be  little  over  100°, 

In  children  of  feeble  constitution,  or  reduced  by  chronic  disease,  the 
fever  may  assume  very  malignant  characters.  When  the  attack  comes  on 
the  patient  becomes  stupid  and  drowsy,  and  then  quickly  passes  into  a 
state  of  coma  from  which  he  never  revives.  Such  cases  are  never  seen  in 
England.  Dr.  Lewis  Smith  states  that  he  has  twice  met  with  this  form 
of  the  disease,  and  that  in  each  instance  the  attack  proved  fatal. 

Children  who  live  in  malarious  districts  often  exhibit  signs  of  ill-health 
without  suffering  from  actual  attacks  of  fever.  Such  patients  are  thin  and 
weakly  ;  the  skin  is  of  a  peculiar  pale  bistre  tint ;  the  mucous  membranes 
are  pallid  ;  the  appetite  is  poor,  and  the  bowels  are  costive  or  relaxed. 
The  spleen  is  permanently  enlarged  and  hard.  If  the  anaemia  is  extreme, 
oedema  of  the  legs  and  ankles  may  be  noticed.  Sometimes,  however, 
oedema  in  these  cases  is  due  to  disease  of  the  kidneys  ;  for  haematuria  and 
albuminuria  are  said  to  be  not  uncommon  symptoms  in  children  living  in 
ague-breeding  neighbourhoods.  Indeed,  in  countries  where  malarious 
fever  is  prevalent  the  origin  of  Bright's  disease  in  the  child  is  frequently 
attributed  to  a  previous  attack  of  ague.  Catarrhal  pneumonia  is  said 
sometimes  to  comphcate  the  illness  and  may  even  pass  into  confirmed 
phthisis. 

The  more  obscure  forms  of  malarious  fever,  which  are  not  uncommon 
in  the  adult,  in  the  child  are  very  rare.  Brow  ague  is  unknown.  Bohn, 
howevei-,  states  that  he  has  met  with  an  intermittent  torticollis  which  he 
believed  to  be  referable  to  a  miasmatic  cause,  and  Dr.  Gibney  has  de- 
scribed an  intermittent  spinal  paralysis  also  of  malarious  origin. 

Diagnosis. — When  the  disease  assumes  the  ordinary  form  met  with  in 
the  adult  it  is  easUy  recognised  ;  but  when,  as  often  happens,  especially  in 
infants  and  the  younger  children,  the  stages  are  imperfectly  marked  and 
the  symptoms  indefinite,  there  is  much  difficulty  in  the  diagnosis.  If  the 
case  occur  in  an  ague-breeding  district,  sudden  illness  and  prostration  with 
a  high  temperature  should  always  excite  our  suspicions,  especially  if  no 
evident  cause,  such  as  vomiting  or  diarrhoea,  exists  to  explain  the  alarming 


150  DISEASE  IN   CHILDRElSr. 

symptoms.  Afterwards  the  sudden  fall  in  the  temperature  which  occurs 
at  the  end  of  the  hot  stage,  and  the  rapid  return  of  apparent  health  as  the 
attack  passes  oft* — these  symj)toms,  combined  with  enlargement  of  the 
spleen,  are  very  suggestive  of  malarious  origin.  When  on  the  next  day,  or 
the  day  after,  the  same  phenomena  recur,  ending  as  before  in  apparent 
recovery,  the  nature  of  the  illness  can  no  longer  be  misapprehended. 

Fits  of  ague  sometimes  occur  in  children  who  are  not  at  the  time  living 
in  a  malarious  district.  If  we  were  suddenly  called  to  a  child  of  whom 
we  had  no  previous  knowledge,  and  found  him  looking  ill  with  a  very  high 
temperature  and  signs  of  severe  general  weakness,  we  should  be  justified 
in  regarding  his  condition  with  grave  apprehension  ;  for  the  fact  of  his 
having  been  lately  exposed  to  the  ague  poison  would  probably  not  be  re- 
ferred to.  In  such  a  case,  after  a  careful  examination  of  the  patient,  we 
should  be  able  to  come  to  no  conclusion,  and  might  probably  suspect  the 
onset  of  one  of  the  exanthemata.  It  would  be  only  on  the  next  visit,  on 
finding  the  patient  whom  we  had  left  in  so  apparently  serious  a  state  look- 
ing and  feeling  well,  Avith  a  normal  temperature,  that  the  nature  of  the 
illness  would  suggest  itself  to  our  minds. 

If,  during  the  hot  stage,  the  body  becomes  covered  with  a  bright  red 
rash,  this  symptom,  combined  with  the  high  temperature  and  perhajDS  slight 
redness  of  the  throat,  may  raise  strong  suspicions  of  scarlatina.  If,  how- 
ever, we  are  aware  that  the  phenomenon  may  occur,  and  find  that  the  rash 
subsides  and  the  temperature  falls  comjDletely  in  the  course  of  a  few  hours, 
we  should  reserve  a  positive  opinion  as  to  the  real  nature  of  the  eruj)tion. 
When,  later,  the  same  phenomena  are  exactly  rejjroduced,  the  natui-e  of 
the  case  can  be  no  longer  doubtful.  Dr.  Cheadle  has  reported  two  such 
cases.  In  one — a  child  aged  two  years  and  nine  months — the  illness 
began  at  9  a.m.  with  a  sharp  rigour.  A  hot  bath  which  was  immediately 
given  brought  out  a  bright  red  rash  all  over  the  body.  At  the  same  time 
the  skin  was  dry  and  burning,  the  temperature  102",  and  the  pulse  110. 
There  was  no  soreness  of  the  throat.  At  the.  end  of  three  hours  the  rash 
faded,  and  the  next  day  the  child  was  playing  about  as  usual.  On  the  fol- 
lowing day — the  third — an  exactly  similar  attack  took  place  ;  and  later  the 
phenomena  were  again  repeated  a  third  time.  Quinine  was  then  given, 
and  the  ague  fits  quickly  came  to  an  end.  In  a  case  such  as  the  above,  if 
there  is  no  redness  of  the  throat  the  resemblance  to  scarlatina  is  less 
close.  Even  if  the  throat  is  sore,  the  peculiar  punctiform  redness  of  the 
soft  palate  which  is  so  common  in  scarlatina  is  wanting ;  and,  moreover, 
the  redness  in  the  fauces  is  less  generally  diffused. 

When  ague  assumes  the  remittent  tyjDC,  as  it  is  apt  to  do  in  feeble, 
badly  nourished  children,  the  diagnosis  is  less  obvious.  In  malarious  dis- 
tricts it  is  well  to  suspect  ague  in  all  cases  where  pyrexia  apjDcars  in  a 
young  child  without  e^ddent  cause.  Still,  the  sources  of  eri'or  are  numer- 
ous ;  for  a  probable  cause  of  elevation  of  temperature,  such  as  dentition, 
may  be  present  in  a  child  who  is  suffering  from  a  real  agueish  attack. 
Perhaps  the  best  rule  in  doubtful  cases  is  to  prescribe  quinine.  W^e  can 
clo  little  harm  by  this  practice,  and  may  do  great  good  by  putting  a  stop  at 
once  to  attacks  which  in  weakly  subjects,  if  not  arrested  early,  may  pro-^ 
duce  very  serious  consequences. 

Prognosis. — If  the  disease  be  recognised  and  treated  promptly  it  can 
usually  be  controlled  with  ease.  The  fatal  cases  are  those  in  which  the 
real  nature  of  the  ilhiess  has  been  misapprehended  and  specific  treatment 
consequently  withheld.  Also,  the  exceptional  cases  where  the  child  ap- 
pears to  be  overwhelmed  by  the  violence  of  the  malarious  poison,   and 


AGUE — TREATMENT.  151 

passes  rapidly  into  a  state  of  coma,  are  said  rarely  to  end  in  recovery. 
But  even  in  these  cases,  if  the  cause  of  the  symptoms  were  recognised 
in  time,  it  is  possible  that  energetic  stimulation  and  the  use  of  quinine  in 
large  doses  by  enema  or  hypodermic  injection  might  be  successful  in 
averting  a  fatal  issue.  It  must  not  be  forgotten  that  in  malarious  dis- 
tricts the  specific  fevers,  and  indeed  acute  illnesses  generally,  tend  to  run 
a  more  severe  course  than  in  healthier  neighbourhoods,  and  that  as  a  rule 
epidemics  have  a  high  rate  of  mortality.  Children  who  suffer  from  the 
ague  cachexia  are  bad  subjects  for  the  eruptive  fevers ;  and  in  all  such 
cases  we  should  speak  with  considerable  caution  as  to  the  patient's  chances 
of  recovery. 

Treatment. — Directly  the  existence  of  ague  is  recognised  in  a  child  spe- 
cific treatment  should  be  had  recourse  to  without  unnecessary  delay.  Chil- 
dren bear  quinine  well.  A  child  of  twelve  months  old  will  take  a  grain 
and  a  half  of  the  sulphate  of  quinine  three  times  a  day,  and  the  fever  will 
quickly  yield  to  this  treatment.  The  best  way  of  administering  the  remedy 
is  to  rub  it  up  with  glycerine  and  give  it  either  in  a  spoon  or  in  a  wine- 
glassful  of  milk  ;  for  milk  helps  to  conceal  the  bitterness  of  the  drug. 
The  medicine  should  be  continued  for  a  few  w^eeks  after  the  attacks  have 
ceased,  but  be  given  in  diminished  quantity  or  less  frequent  doses.  At 
the  same  time  it  is  desirable  to  remove  the  child  from  the  malarious  neigh- 
bourhood. If  this  be  impossible,  it  is  well  to  give  a  dose  of  quinine  twice 
a  Vyeek  for  a  considerable  time  after  the  subsidence  of  the  seizures. 

In  cases  where  the  child  vomits  the  quinine,  or  where  from  other  rea- 
sons it  is  not  desired  to  administer  the  remedy  by  the  mouth,  it  may  be 
thrown  up  the  bowel  suspended  in  a  small  quantity  of  mucilage,  or  may 
be  given  by  hypodermic  injection.  In  the  former  case  the  dose  must  be 
double  that  previously  recommended  for  administration  by  the  mouth. 
If  the  remedy  is  administered  subcutaneously.  Dr.  Eahking  recommends 
that  the  neutral  sulphate  of  quinine  be  used  freshly  dissolved  in  warm 
water  ;  that  the  syiinge  and  solution  be  both  warmed  before  use  ;  and  that 
the  injection  be  made  very  slowly,  distributing  the  fluid  at  the  same  time 
amongst  the  interstices  of  the  cellular  tissue  by  the  forefinger  of  the  left 
hand,  so  that  no  lump  is  left  to  mark  the  site  of  the  puncture.  It  is  found 
that  warming  the  solution  and  the  syringe  not  only  lessens  the  pain  of  the 
operation,  but  also  reduces  the  tendency  of  the  quinine  to  deposit  itself 
quickly  in  the  cellular  tissue.  If  used  cold  the  quinine  is  almost  always 
deposited  at  once  in  a  solid  mass  before  absorption  of  the  solution  can 
take  place.  This  is,  however,  not  injurious,  but  it  retards  the  beneficial 
effect  of  the  operation.  The  quantity  of  the  drug  thus  administered 
should  be  a  fifth  of  that  given  by  the  mouth.  For  an  adult  the  dose  is  half 
a  grain.  Probably  one-sixth  of  a  grain  would  be  a  suitable  quantity  for  a 
child  of  two  or  three  years  old.  In  order  to  prevent  corrosion  of  the 
syringe  it  is  advisable  directly  after  the  operation  to  wash  the  instrument 
in  hot  water  and  dry  it  carefully,  and  afterwards  to  oil  the  screw  well. 
Instead  of  the  sulphate  the  kinate  of  quinine  may  be  used.  Mr.  H.  Collier 
has  recommended  this  salt  as  the  more  suitable  on  account  of  its  solubility 
for  hypodermic  administration. 

In  some  cases,  especially  in  the  older  children,  where  there  is  much 
acute  enlargement  of  the  liver  and  spleen,  quinine  seems  to  be  useless.  In 
these  cases  it  is  of  great  importance  to  reduce  the  congestion  of  the  liver 
before  beginning  the  quinine  treatment.  The  child  should  take  at  night  a 
dose  of  gTay  powder  (gr.  iv.)  with  jalapine  or  compound  scammony  powder, 
and  the  action  of  the  bowels  should  be  kept  up  for  a  week  or  two  by  doses 


153  DISEASE  ITT   CHILDEEN. 

of  some  aperient  saline.  Sulphate  of  magnesia  is  very  usefiol  for  this  pur- 
pose, given  with  dilute  sulphuric  acid  and  half  a  gTain  of  quinine  for  the  dose. 
The  medicine  can  be  made  palatable  with  spirits  of  chloroform,  glycerine, 
and  tincture  of  orange  peel.  After  the  liver  has  been  unloaded,  the  quinine 
treatment  in  full  doses  can  be  returned  to,  or  the  child  can  take  arsenic 
(TT[  v.-x.  of  the  solution  three  times  a  day  for  a  child  ten  years  of  age),  with 
or  without  quinine,  directly  after  meals. 

In  the  more  chi'onic  cases,  a  combination  of  quinine  and  arsenic  with 
iron  is  very  useful.  It  is  also  of  great  importance  that  the  child  be  re- 
moved from  the  malarious  district  to  a  bracing  seaside  au*.  Moreover,  he 
should  be  dressed  from  head  to  foot  in  flannel  or  some  woollen  material 


CHAPTER  III. 

ACUTE   RHEUMATISM. 

Eheumatio  inflammation  of  the  fibrous  tissues  is  a  common  affliction  in 
early  life.  In  childhood,  indeed,  there  appears  to  be  a  pecuhar  tendency 
to  rheumatism  ;  and  in  young  people  the  disease  may  assume  very  special 
characters.  The  joints  are  generally  affected,  but  other  fibrous  structures 
suffer  as  well.  More  often  than  in  the  adult  the  articular  inflammation  is 
absent,  and  not  infrequently  it  is  very  partial  and  takes  an  insignificant 
share  in  the  iUness. 

The  great  importance  of  rheumatism  in  children  is  due  to  the  inflam- 
mation in  and  around  the  heart,  of  which  it  is  so  frequently  the  cause." 
The  large  majority  of  cases  of  heart  disease  are  the  consequence  of  rheu- 
matic endocarditis  occurring  in  early  life.  But  besides  the  heart  other 
fibrous  structures  may  be  attacked.  The  pleura  may  be  affected  ;  the 
meninges  of  the  brain  and  spinal  cord  may  suffer  ;  and  sometimes  fibrous 
tissues  in  other  situations  may  be  imphcated,  as  will  be  afterwards  de- 
Bcribed. 

Acute  rheumatism  is  said  to  be  uncommon  under  five  years  of  age  ; 
but  the  accuracy  of  this  assertion  is  open  to  question.  Infants  and  young 
children  may  not  suffer  from  much  articular  swelling  and  pain,  but  it  is  a 
common  experience  to  detect  a  cardiac  murmixr  at  the  mitral  orifice  in  a 
young  child,  and  to  discover,  on  inquiry,  that  the  patient  had  some  weeks 
or  months  previously  been  feverish,  with  a  little  stiffness  and  tenderness 
of  one  or  more  joints,  symptoms  amply  sufficient  to  estabhsh  the  rheumatic 
origin  of  the  cardiac  disease. 

Causation. — The  principal  cause  of  rheumatism  is  exposure  to  cold,  or  to 
cold  and  damp.  In  young  children  and  infants  a  very  slight  impression  of 
cold  may  suffice  to  set  up  the  disease.  Thus,  I  have  known  a  young  child 
exposed  to  draught  from  the  nui-sery  door,  while  being  dried,  after  a  bath, 
before  the  fire,  suffer  shortly  afterwards  from  stiffness  and  pain  in  the 
knees  and  endocarditis.  Sudden  changes  of  temperature  are  favoiirable  to 
the  production  of  rheumatism.  In  England  the  disease  is  much  more  rife 
during  the  spring  and  the  autumn,  when  the  evenings  suddenly  tm-n  chilly 
and  damp,  than  in  the  winter  months  when  the  temperature  is  more  uni- 
form. 

Many  influences  favom-  the  action  of  cold  and  moisture  in  producing 
rheumatism.  Family  tendency  will  do  this.  A  large  proportion  of  rheu- 
matic children  come  of  rheumatic  parents.  Again,  previous  illness  of  the 
same  kind  predisposes  to  fresh  attacks.  When  a  child  has  once  suffered 
from  rheumatism,  he  is  very  hkely  to  suffer  from  it  a  second  time.  The 
state  of  the  health  at  the  time  of  the  exposiure  exerts  some  influence.  The 
existence  of  catarrh  of  any  mucous  membrane  renders  the  jDatient  very 
sensible  to  chills,  and  makes  exposure  very  dangerous  to  a  child  of  rheu- 


154  DISEASE   IN   CHILDEEN. 

nmtic  tendencies.  Lastly,  scarlatina  predisposes  witli  peculiar  force  to 
rheumatism  or  to  a  disease  indistinguishable  from  it. 

3Iorhid  Anatomy.  —  "When  a  joint  becomes  the  seat  of  rheumatic  in- 
flammation, there  is  reddening  of  the  synovial  membrane  lining  the  joint, 
the  synovial  fluid  is  increased  in  quantity  and  often  milky,  and  there  is 
some  eflusion  of  fluid  into  the  surrounding  tissues.  Sup^Duration  in  the 
joint  is  very  rare. 

In  pericarditis  the  pericardium  is  reddened  and  softened,  exudation 
of  lymph  occurs  on  the  serous  sui'face,  and  fluid  is  effused  into  the  cavity. 
The  serous  fluid  and  the  more  solid  lymph  vary  greatly  in  amount,  and 
either  may  be  in  excess.  The  quantity  of  fluid  thrown  out  is  sometimes 
enormous.  It  may  be  clear  or  opalescent,  or  tinted  red  from  blood. 
Sometimes,  as  in  pleurisy,  although  far  less  fi'equently  than  in  that  disease, 
the  fluid  is  purulent.  The  layer  of  lymjDh,  also,  may  reach  a  great  thick- 
ness. It  may  be  smooth,  or  pitted  with  holes  hke  a  honeycomb,  or  ribbed 
like  the  sea-sand.  Sometimes  the  visceral  and  parietal  layers  are  united 
by  soft  thick  bands  of  Ij-mph.  If  the  inflammatory  process  in  the  pericar- 
dlum.  is  severe,  the  heart  substance  towards  the  surface  is  generally  sof- 
tened to  a  certain  extent  and  weakened.  If  much  13'mph  has  been  thrown 
out,  more  or  less  complete  adhesion  is  likely  to  take  place,  after  absorp- 
tion of  the  fluid,  between  the  ojDposed  surfaces  of  the  serous  membrane. 

In  endocarditis  the  morbid  ajDiDearances,  when  not  congenital,  are 
limited  almost  invariably  to  the  left  side  of  the  heart.  The  valves  become 
thickened  and  softened,  and  very  soon  granular  on  the  surface.  The 
granulations  enlarge  and  develop  into  the  so-called  vegetations  —  out- 
growths from  the  fibrous  tissue  of  the  valve  which  may  vary  greatly  in 
shape  and  size.  They  consist  of  connective  tissue  more  or  less  perfectly 
organised.  They  are  usually  limited  to  the  auricular  sui-f ace  of  the  valve, 
and  are  often  iDartially  covered  by  fibrinous  deposits.  Granulations  may 
also  develop  on  the  chordae  tendinese.  The  softened  tissue  of  the  valve 
may  tear,  or  the  chordae  tendineae  may  rupture  ;  and  the  tension  of  the 
valve  and  the  closure  of  the  orifice  may  be  seriously  interfered  with.  After 
a  time  the  valves  may  become  thickened,  contracted,  and  hardened. 
Sometimes  they  adhfere  to  one  another  or  ,  to  the  wall  of  the  ventricle.  In 
this  way,  also,  the  proper  closure  of  the  openuig  may  be  impossible,  and 
the  opening  itself  may  be  narrowed  and  altered  in  shaj)e. 

Ulceration  may  take  place,  seriously  aflecting  the  valve  itself,  and  tend- 
ing to  produce  other  grave  consequences.  It  is  the  washing  into  the  cir- 
culation of  fibrinous  deposits  and  jDarticles  of  disintegrated  tissue  from  the 
ulcerated  surface  that  produces  embolism  in  distant  organs — the  brain,  the 
'kidnej,  or  the  spleen. 

Symptoms. — The  disease  begins  suddenly.  The  child,  if  old  enough, 
complains  of  cold,  and  sits  over  the  fire.  He  is  unwiUing  to  move  about, 
sometimes  vomits,  and  may  feel  some  stiffiiess  of  the  articulations.  Soon, 
pain  is  complained  of  in  one  or  more  joints,  and  the  child  takes  to  his  bed. 
When  the  patient  comes  under  observation  his  temperature  is  moderately 
high — 102°  or  103°.  His  skin  is  generally  moist  with  a  sour-smeUing  per- 
spiration, and  on  inspection  we  find  the  affected  joints  tender,  swollen, 
and  suffused  with  a  pink  blush.  The  child  is  thirsty,  has  little  appetite, 
and  his  tongue  is  furred.  The  urine  is  high-coloured  and  scanty,  and  is 
often  thick  with  lithates.  The  bowels  are  confined.  The  patient  may 
wander  at  night ;  he  sleeps  badly  on  account  of  the  pain  ;  and  for  these 
reasons  (pain  and  want  of  sleep)  his  face  is  often  haggard-looking,  and  his 
expression  distressed. 


ACUTE  EHEUMATISM — SYMPTOMS.  155 

The  pain  is  at  first  of  only  moderate  severity,  but  gradually  grows 
worse.  As  long  as  the  child  is  quiet  and  undisturbed  he  may  not  make 
much  complaint ;  but  if  the  limb  is  touched,  or  the  bed  is  shaken,  he  at 
once  shows  signs  of  distress.  The  degree  of  pain  and  the  amount  of  swell- 
ing around  the  joint  seem  to  bear  no  relation  to  one  another.  The  artic- 
ulations affected  are  usually  the  larger  ones — the  hips,  the  knees,  elbows, 
ankles  and  wrists.  It  is  exceptional  for  the  small  joints  of  the  fingers 
and  toes  to  be  painful  and  swoUen.  Usually  one  or  two  joints  are  first 
attacked  ;  these  recover,  and  others  become  inflamed.  The  whole  illness 
may  last  a  variable  time,  but  the  duration  of  the  inflammation  in  each 
particular  joint  is  comparatively  short.  It  may  pass  away  in  a  few  hours, 
and  rarely  lasts  longer  than  a  day  or  two.  Sometimes,  after  leaving  a  joint 
and  passing  to  another,  the  inflammation  returns  to  the  joint  first  affected; 
and  in  this  way,  if  the  illness  be  a  long  one,  the  same  joint  may  be  at- 
tacked again  and  again  before  the  energy  of  the  disease  is  exhausted. 
Even  when  the  attack  appears  to  be  at  an  end,  a  sudden  return  of  the  symp- 
toms may  distress  and  disappoint  the  patient  and  his  friends.  Relajjses  are 
very  common  in  rheumatic  fever,  and  the  symptoms  may  return,  after  a 
more  or  less  complete  subsidence,  two,  three,  four,  or  even  five  times. 

The  articular  inflammation,  although  the  part  of  the  disease  which 
causes  the  greatest  discomfort  to  the  patient,  is  yet,  as  it  seldom  produces 
after  ill- consequences,  of  comparatively  trifling  moment.  A  far  more  im- 
portant feature  is  the  heart  affection,  which  is  so  common  an  expression  of 
the  malady.  Inflammation  of  the  fibrous  structures  in  and  around  the 
heart  is  an  essential  part  of  the  disease,  as  it  attacks  young  persons,  and 
must  not  be  regarded  as  a  mere  casual  complication.  In  exceptional 
cases,  indeed,  a  child  may  have  rheumatic  fever  and  the  heart  may  escape  ; 
but  in  rheumatism  all  the  fibrous  structures  of  the  body  need  not  be  af- 
fected at  once.  The  patient  may  have  inflammation  of  one  joint  and 
not  of  another  ;  the  right  wrist,  for  instance,  may  be  affected  and  the  left 
may  escape  ;  one  leg  ma}'  be  crippled  and  the  other  sound.  So  the  disease 
may  attack  the  joints  and  leave  the  heart  alone,  as  it  may  attack  the  heart 
and  spare  the  joints.  The  younger  the  child  the  more  likely  is  it  that  the 
disease  will  fasten  upon  the  heart  to  tte  exclusion  of  the  articulations. 

The  occurrence  of  rheumatic  inflammation  of  the  heart  and  pericardium 
is  not  at  once  announced  by  any  striking  change  in  the  s^^mptoms,  or  even 
in  the  aspect  of  the  patient.  Indeed,  it  is  matter  for  surprise  how  complete 
in  most  cases  is  the  absence  of  all  external  indications  that  so  imj)ortant  an 
addition  has  been  made  to  his  illness.  Often  the  onl}'  sign  of  implication 
of  these  organs  is  derived  from  physical  examination  of  the  chest. 

In  rheumatic  inflammation  of  the  pericardium  there  is  in  ordinary  cases 
neither  pain  nor  tenderness  ;  we  notice  no  special  hurry  of  breathing  or  of 
pulse  ;  the  heart's  action  may  be  irregular,  but  there  are  no  palpitations ; 
there  is  little  change  of  colour  in  the  face  ;  and,  unless  the  joint  affection 
be  severe,  the  temperature  may  be  only  moderately  raised,  or  may  even  be 
normal.  In  spite,  however,  of  the  absence  of  symjDtoms,  the  child  looks 
ill  ;  and  while  up  and  about — as  he  usually  is  before  coming  under  the  no- 
tice of  the  medical  attendant,  if  the  articular  inflammation  is  not  severe — 
his  countenance  wears  an  expression  of  distress  which  quickly  attracts  the 
attention  of  his  friends. 

A  little  girl,  aged  three  years  and  a  half,  was  admitted  into  the  East 
London  Children's  Hospital.  She  had  had  a  slight  cough  for  a  fortnight, 
and  was  said  to  have  looked  iU.  On  examination,  there  was  found  dul- 
ness  of  pyramidal  shape  in  the  prsecordial  region  reaching  upwards  to  the 


156  DISEASE  IlSr   CHILDRElSr. 

left  sterno-clioncTral  clavicular,  and  to  the  right  as  far  as  one  unger's- 
breadtli  beyond  the  right  edge  of  the  sternum.  The  apex-beat  of  the  heart 
was  behind  the  fifth  rib,  shghtly  to  the  inner  side  of  the  nipple  Hne.  A 
faint  impulse  was  felt  all  over  the  praecordium.  The  heart-sounds  were 
muffled,  aud  a  soft  double  friction-sound  was  heard  at  the  base.  The  child 
complained  of  no  pain.  There  was  no  affection  of  the  joints.  The  other 
organs  were  healthy  and  the  temperatui-e  was  normal.  A  week  after- 
wards it  was  noted  :  "  The  cardiac  dulness  is  as  at  last  report,  and  there 
is  the  same  friction  to  be  heard  over  the  pra?cordial  region.  Since  admis- 
sion the  child  has  had  no  symptoms,  and  the  temperature  has  been  gen- 
erally subnormal.  Still  the  patient  looks  ill,  and  there  is  a  distressed  ex- 
pression on  the  face  even  during  sleep.  Is  now  (3  p.m.)  lying  asleep  on  her 
back,  inclining  to  the  left  side.  Pulse  88,  regular  ;  respiration  28,  nares  hot 
acting.  Some  shght  hvidity  about  the  mouth  and  under  the  eyes.  Gen- 
eral pallor  of  face,  with  a  faint  tinge  of  pink  on  her  cheeks.  Lips  rather 
pale.  The  superficial  veins  are  visible  over  the  sides  of  the  neck  and  the 
backs  of  the  hands,  although  not  greatly  enlarged."  After  a  few  weeks  the 
■physical  signs  of  the  heart  became  normal,  and  the  child's  health  was  per- 
fectly restored. 

The  above  illustrates  very  weU  the  general  appearance  of  a  child  who  is 
the  subject  of  pericarditis.  In  the  lai-ge  majority  of  cases,  although  he  may 
look  ill  and  be  lang-uid,  yet  if  there  be  no  joint  affection,  he  makes  no  spe- 
cial complaint.  An  examination  of  the  chest  at  once  reveals  the  cause  of 
the  indisposition. 

Still,  it  is  right  to  say  that  in  exceptional  cases  much  more  serious  symp- 
toms may  be  noticed.  There  may  be  tumultuous  action  of  the  heart,  with 
gi-eat  dyspnoea  or  even  orthopnoea,  and  Kridity  of  the  face.  The  cotmte- 
nance  may  express  the  utmost  anxiety,  and  the  restlessness  may  be  extreme. 
There  is  usually,  also,  some  puffiness  of  the  face,  and  slight  but  general 
oedema.  The  gravity  of  these  cases  is  probably  owing  to  the  participation 
of  the  heart  substance  in  the  inflammation.  Again,  in  still  other  cases  we 
find  symptoms  all  pointing  to  the  brain.  There  is  high  fever,  with  head- 
ache and  dehrium  (see  page  159).  Such  cases  are,  however,  chiefly  inter- 
esting from  their  rarity.  They  occur  very  seldom  even  in  hospital  prac- 
tice, and  are  clinical  cuiiosities  which  for  practical  purposes  may  be  put 
on  one  side. 

The  beginning  of  pericardial  inflammation  is  indicated  by  a  more  or 
less  loud  rub  of  friction  accompanying  the  sounds  of  the  heart.  The  rub" 
is  best  heard  at  the  base,  and  is  double,  the  systole  and  diastole  being  ac- 
companied by  a  distinct  catch  or  scrape,  which  is  very  superficial,  and  con- 
veys the  impression  of  being  generated  at  a  point  neai-er  to  the  ear  than  the 
sounds  of  the  heart  themselves.  Even  if  there  be  at  the  same  time  an  en- 
docardial murmui',  the  friction  sound  can  be  in  most  cases  readily  sepa- 
rated by  the  practised  ear,  through  its  higher  pitch  and  more  superficial 
character,  fi'om  the  lower  pitched  and  more  deeply  sounding  murmur-  gene- 
rated by  the  inflamed  valve.  A  pericardial  friction-sound  is  not,  however, 
always  'high  pitched,  and  even  its  supei-ficial  character  may  not  be  so  de- 
cidedly marked  as  would  be  expected.  In  certain  cases  a  loud  blowing 
sound  is  heard,  which  is  indistinguishable  by  the  ear  alone  from  a  similar 
sound  of  endocardial  origin.  Its  mechanism  must  be  then  decided  by 
other  considerations. 

At  first  there  is  no  alteration  in  the  pra^cordial  dulness,  but  in  a  day 
or  two,  as  fluid  is  poured  out  from  the  inflamed  serous  membrane,  the 
limits  of  th-e  heart's  dulness  are  extended.     At  the  same  time  the  position 


ACUTE   EIIEUMATISM — SYMPTOMS — PEEICAllDITIS.  157 

of  the  apex-beat  of  the  heart  is  raised,  and  the  cardiac  impulse  is  feebler 
than  before. 

A  little  girl,  aged  seven  years,  had  a  mild  attack  of  rheumatism  fol- 
lowed by  chorea.  Six  months  afterwards  the  choreic  movements  returned, 
and  she  was  admitted  into  the  East  London  Children's  Hospital.  At  this 
time  the  heart's  apex  was  noted  to  be  beating  between  the  fifth  and  sixth 
ribs,  one-fourth  of  an  inch  outside  the  nipple  line  ;  and  a  soft  systohc 
murmur  was  heard  at  this  spot.  After  being  a  few  days  in  the  hospital, 
the  child's  temperature  rose  from  normal  to  103.8°,  and  a  double  rub  was 
detected  over  the  prsecordial  region.  There  was  also  a  patch  of  pneumo- 
nia at  the  base  of  the  right  lung.  Some  days  afterwards  effusion  was 
found  to  have  occui-red  in  the  iDericardium,  the  limits  of  the  heart's  dulness 
were  extended,  and  the  heart's  apex  was  raised  to  between  the  fourth  and 
fifth  ribs  in  the  nipi^le  line.  The  double  friction  was  still  heard — most 
distinctly  at  the  level  of  the  third  left  sterno-chondral  articulation. 

If  much  lymph  and  little  fluid  be  thrown  out,  the  hand  placed  upon 
the  prsecordial  region  can  often  detect  a  distinct  fremitus  with  each  beat 
of  the  heart.  When  a  considerable  quantity  of  fluid  is  effused  into  the 
pericardium,  the  resulting  area  of  dulness  takes  the  shape  of  the  contain- 
ing sac.  It  becomes  triangular  or  "pyramidal"  in  form,  with  the  apex  di- 
rected upwards  towards  the  top  of  the  sternum.  A  moderate  effusion  does 
not  prevent  the  friction-sound  from  being  heard,  but  the  rub  becomes  less 
intense  and  less  crisp  than  before,  and  the  heart-sounds  are  muffled  and 
distant.  In  great  effusion  the  chest-wall  in  the  cardiac  region  may  be 
bulged,  and  on  careful  inspection  the  eye  can  often  detect  a  distinct 
undulatory  movement  with  each  beat  of  the  heart  in  the  intercostal 
spaces. 

An  important  distinguishing  mark  of  pericardial  friction  is,  besides  its 
superficial  character,  the  irregularity  of  distribution  of  the  sound.  Endo- 
cardial murmurs  are  carried  along  with  the  blood-current.  Pericardial 
frictions  may  be  limited  to  a  small  area,  or  heard  equally  loudly  over  the 
whole  praecordial  region  ;  in  either  case  they  do  not  follow  the  rules 
which  regulate  the  transmission  of  heart-murmurs.  Further,  a  pericardial 
rub  is  intensified  by  pressure,  and  is  heard  better  during  expiration  than 
when  the  lungs  are  expanded.  As  the  fluid  and  lymph  become  absorbed, 
the  limits  of  dulness  gradually  return  to  their  former  dimensions  ;  and  the 
friction  after  a  time  becomes  fainter  and  fainter  and  gradually  disappears. 
If  the  lymph  has  been  exuded  in  large  quantity,  adhesion  of  the  pericar- 
dium may  take  place.  Unless  there  be  also  adhesion  between  the  j)ericar- 
dium  and  the  adjacent  pleura,  there  are  no  physical  signs  by  which  this 
condition  can  be  detected.  If  the  pleui-a  and  pericardium  be  adherent, 
the  intercostal  space  corresponding  to  the  apex  of  the  heart  is  depressed 
at  each  impulse.  Adherent  pericardium  is  generally  followed  by  hyper- 
trophy of  the  heart. 

The  flaid  in  pericarditis  sometimes  becomes  purulent.  The  suppu- 
rative form  of  pericarditis  is  more  common  in  cases  where  the  inflammation 
has  extended  to  the  pericardium  from  the  pleura  ;  although  it  may  no 
doubt  also  occur  without  the  pleura  having  been  previously  affected.  In 
the  cases  of  this  form  of  pericardial  inflammation  which  have  come  under 
my  notice,  the  patients  have  complained  of  pains  in  the  chest  or  epigas- 
trium ;  the  temperature  has  been  high  at  night  (103'^  to  104°),  with  a  par- 
tial morning  remission  ;  pericardial  friction  has  disappeared  early  ;  ab- 
sorption of  the  effusion,  if  it  had  begun  at  all,  has  been  slow  and  incom- 
plete, and  towards  the  end  of  the  disease  slight  but  general  oedema  has  been 


158  DISEASE  IN   CHILDEEN". 

noticed  without  any  albumen  being  discovered  in  tbe  urine.  These  cases 
almost  always  end  fatally. 

When  endocarditis  occiu-s,  the  valvular  lesion  is  indicated  at  first  by 
no  external  signs,  and  can  only  be  discovered  by  physical  examination. 
With  the  stethoscope  we  hear  a  low-pitched  soft  murmur  at  some  point  of 
the  prsecordial  surface,  indicating,  according  to  its  site  and  rhythm,  ob- 
struction or  incompetence  of  one  or  another  of  the  cardiac  valves.  The  af- 
fection of  the  valve  may  be  accompanied  b}'  increased  frequency  of  the 
pulse  and  some  paljDitation  ;  but  while  the  patient  is  at  rest  in  bed  these 
symptoms  are  very  exceptional.  Tenderness  is  never  present,  and  it  is 
rare  for  the  child  to  complain  of  pain  or  uneasiness  about  the  chest.  The 
valve  affected  is  most  commonly  the  mitral,  although  the  aortic  semilunar 
valves  are  sometimes  inflamed  alone,  or  in  conjunction  with  it.  The  le- 
sions are  almost  invariably  limited  to  the  left  side  of  the  heart. 

Endocarditis  may  occur  without  implication  of  the  pericardium,  or  the 
two  lesions  may  be  combined.  In  the  latter  case  the  endocardial  murmur 
may  be  completely  masked  by  the  external  friction-sound,  and  may  only  be 
discovered  as  the  latter  subsides.  If  unaccompanied  by  inflammation  of 
the  pericardium,  endocarditis,  although  a  very  serious  misfortune  as  re- 
gards the  future  of  the  patient,  adds  little,  if  anything,  to  the  immediate 
danger. 

There  is  one  accident  which  sometimes  occurs  as  a  direct  result  of  en- 
docarditis. The  vegetations  on  the  inflamed  valve  may  undergo  disinte- 
gration, and  minute  particles  swept  away  into  the  general  circulation  may 
become  arrested  in  the  small  arteries  of  a  distant  organ.  Ulcerative  en- 
docarditis is  not  a  common  disease  in  children,  but  it  is  occasionally  met 
wdth.  This  complication  gives  rise  to  symptoms  which  may  be  mistaken 
for  those  of  pyaemia  or  of  continued  fever,  so  close  sometimes  is  the  re- 
semblance. They  are  partly  constitutional,  owing  to  admixture  with  the 
blood  of  decaying  atoms  of  oi'ganic  matter  from  the  disintegrating  valve  ; 
partly  local,  from  embolisms  which  interfere  with  the  function  of  special 
organs.  Thus  there  is  high  fever  with  marked  remissions  ;  great  weak- 
ness and  prostration  ;  a  furred  dry  tongvie  ;  often  sickness,  and  i:)erhaps 
diarrhoea,  thirst,  and  anorexia.  The  pulse  is  small,  rapid,  and  weak  ;  the 
breathing  hurried  ;  and  the  child  gradually  becomes  restless  and  deli- 
rious, or  drowsy  and  comatose.  The  local  symptoms  are  derived  from  the 
organ  or  organs,  whose  function  is  interfered  with  by  arrest  of  emboli  in 
their  mmute  arteries  or  capillaries.  Thus,  embolisms  in  the  skin  produce 
petechias  from  minute  extravasations  ;  in  the  liver,  swelling  and  perhaps 
jaundice  ;  in  the  kidney,  albumen  and  blood  in  the  water  ;  in  the  spleen, 
swelling  and  tenderness  ;  in  the  brain,  paralysis  ;  or  if  from  small  dissemin- 
ated emboli,  headache,  deluium,  and  coma,  without  special  interference 
with  motor  function.  In  all  these  cases  examination  of  the  heart  reveals  the 
signs  of  valvular  disease.     The  cases  generally  end  fatall}^ 

The  pleui'a  is  often  affected  in  rheumatism,  alone  or  in  conjunction  with 
the  pericardium.  Pleurisy  and  pericarditis  may  occur  simultaneously,  or 
the  inflammation  may  spread  from  one  membrane  to  the  other.  When 
the  two  diseases  are  present  together,  the  inflammatory  processes  in  the 
two  situations  may  be  perfectly  independent  the  one  of  the  other.  The  ef- 
fusion in  the  pleura  may  be  purulent,  and  that  in  the  pericardium  serous ; 
or  the  pericardium  may  contain  pus,  and  the  pleura  pure  serum. 

A  little  boy,  aged  six  years,  died  in  the  East  London  Children's  Hos- 
pital of  pleurisy  and  pericarditis.  On  examination  the  right  lung  was 
found  adherent  to  the  pericardium,  and  partially  to  the  chest  wall.     It  was 


ACUTE   RHEUMATISM — CEREBRAL   SYMPTOMS.  159 

condensed  and  tougli  from  pressure,  and  the  pleura  of  that  side  contained 
a  large  quantit}'  of  clear  fluid.  The  pericardium  was  adherent  to  the  heart 
in  places,  and  in  the  sac  were  about  two  ounces  of  thick  pus.  In  this  case 
the  illness  had  begun  ^Yith  sickness  and  pain  in  the  side,  followed  by  cough 
— symptoms  which  pointed  to  pleurisy  ;  and  tkree  weeks  afterwards,  when 
the  child  first  came  under  observation,  there  was  slight  but  distinct  con- 
traction of  the  right  side,  shown  by  lowering  of  the  shoulder  and  angle 
of  the  scapula,  with  distinct  curving  of  the  spine — the  convexity  to  the 
left.  These  signs,  taken  in  conjunction  with  the  history,  seemed  to  indi- 
cate that  the  pleurisy  had  dated  from  the  beginning  of  the  illness,  and 
that  therefore,  if  it  did  not  give  rise  to  the  pericarditis,  was  not,  at  any  rate, 
secondary  to  it. 

Pneumonia  is  not  rare  in  rheumatic  fever,  and  may  occur  in  conjunc- 
tion with  pleurisy  or  independently  of  it.  A  much  i-arer  lesion  is  menin- 
gitis affecting  the  membranes  at  the  convexity  of  the  brain  and  those  of 
the  spine.  These  cases  are  characterised  by  high  fever,  headache,  and  de- 
lirium. Still,  we  must  not  sujDpose  that  in  every  instance  where  siich 
symptoms  occur  in  the  course  of  acute  rheumatism  they  are  due  to  inflam- 
mation of  the  cerebral  meninges.  Many  cases  are  now  on  record  in 
which  these  symptoms  have  been  present,  with  others — all  pointing  to  the 
head  as  the  seat  of  the  lesion,  and  yet  on  dissection  of  the  dead  body  no 
signs  of  disease  have  been  discovered  within  the  cranium.  Dr.  Latham 
has  described  a  case  of  this  kind  which  occurred  in  a  little  scholar  at  Christ's 
Hospital.  The  boy  had  high  fever,  headache,  delirium,  and  convulsions  ; 
and  died  in  spite  of  energetic  treatment  directed  against  a  supposed  men- 
ingitis. Examination  of  the  body  disclosed  no  disease  of  the  brain  or  its 
membranes  ;  instead,  there  were  all  the  signs  of  a  severe  pericarditis — a 
disease  which  had  not  been  so  much  as  suspected  during  life.  Trous- 
seau believed  this  form  of  "  cerebral  rheumatism,"  which  leaves  no  trace 
of  intracranial  inflammation  behind  it,  to  be  a  neurosis  depending  upon 
some  such  mysterious  modification  of  nerve-substance  as  is  believed  to  oc- 
cur in  hysteria  and  tetanus.  The  symptoms  may,  however,  be  explained 
more  simply  by  attributing  them  merely  to  the  effects  of  hyperpyrexia  ; 
and  this  is  the  view  commonly  accepted  in  the  present  day.  Such  a  case 
has  never  come  under  my  observation  ;  nor  have  I  ever  seen  a  case  of 
rheumatic  iritis  in  the  child,  nor  of  peritonitis  occurring  in  the  coiu'se  of 
acute  rheumatism. 

Peritonitis  may,  however,  be  simulated  by  rheumatism  of  the  abdomi- 
nal muscles  which  sometimes  occurs  in  children.  If  this  be  severe,  there 
is  tenderness  on  j)resstu"e  of  the  abdominal  wall,  the  child  may  have  an 
appearance  of  great  distress,  and  maj'  lie  in  bed  with  his  knees  flexed  on 
his  abdomen,  as  if  he  were  really  suftering  from  inflammation  of  the  peri- 
toneum. The  bowels  are  usually  confined.  These  cases  may  be  readily 
distinguished  by  careful  examination.  The  face,  although  often  distressed, 
has  not  the  haggard  look  which  is  so  characteristic  of  peritonitis  ;  there  is 
little  or  no  tension  of  the  abdominal  wall  ;  the  natural  markings  are  not 
lost ;  the  tenderness  is  not  extreme  ;  the  pulse  is  soft,  compressible,  and 
of  moderate  quickness,  not  rapid  and  hard  ;  and  the  temperature  is  normal 
or  only  shghtly  elevated.  There  is  generally  great  acidity  of  urine  ;  it  is 
scanty  and  high-coloured,  and  its  passage  may  cause  some  scalding. 

Torticolhs  (stiff-neck)  is  sometimes  a  consequence  of  rheumatism.  The 
disease  may  affect  the  muscles,  especially  the  sterno-mastoid  ;  or  may  at- 
tack the  fibrous  ligaments  uniting  the  vertebrfe.  The  nervous  sj^stem,  too, 
may  suffer.     Neuralgia  has  been  noticed  in  some  children  ;  and  pai'alysis 


160  DISEASE   IlSr   CHILDEEK. 

of  tlie  muscles  of  ons  side  of  the  face  may  be  produced  by  rheumatic  in- 
flammation of  the  sheath  of  the  facial  nerve  at  its  point  of  exit  from  the 
bone.  Moreover,  there  is  an  evident  connection  between  rheumatism  and 
chorea.     This  important  subject  will  be  considered  elsewhere  (see  Chorea). 

A  peculiar  manifestation  of  rheumatism  is  sometimes  found  in  chil- 
dren. This  was  first  noticed  by  Meynet,  and  is  characterized  by  swellings 
varying  in  number  and  size  which  appear  in  the  tendons  and  their  sheaths, 
and  in  other  fibrous  structures  which  lie  close  under  the  skin.  Thus  they 
are  seen  around  the  patella  and  the  malleoli ;  on  the  spinous  processes  ;  on 
the  temporal  ridge,  and  on  the  superior  cun^ed  line  of  the  occiput.  They 
are  very  hard  ;  are  accompanied  by  no  redness,  tenderness,  or  pain  ;  are 
sometimes  movable  ;  and  disapjoear  after  a  time  spontaneously.  They 
are  composed  of  small  masses  of  loose  fibrous  bundles,  and  are  very  vas- 
cular. 

A  little  girl,  nearly  ten  years  old,  was  under  my  care  in  the  East  Lon- 
don Children's  Hospital  for  an  attack  of  rheumatic  fever  comphcated  with 
chorea.  She  had  a  harsh  systohc  murmur  at  the  apex  of  her  heart,  which 
evidently  dated  from  a  previous  attack  of  endocarditis ;  but  the  apex-beat 
was  not  displaced,  nor  were  the  normal  limits  of  the  heart's  duhiess  ex- 
tended. In  this  child  fibrous  nodules  were  found  on  the  spinous  processes 
of  the  vertebrae,  the  prominences  of  the  scapula,  the  head  of  the  radius, 
the  tendons  in  fi'ont  of  the  right  ankle,  and  the  back  of  the  right  hand. 
The  nodules  varied  in  size  from  a  split  pea  to  a  large  marble  ;  they  were 
not  tender,  and  the  skin  over  them  was  not  adherent.  While  the  child  re- 
mained in  the  hospital  her  temperature  never  at  any  time  rose  above  100°. 
The  swellings  gradually  diminished  in  size,  and  by  the  end  of  the  month 
had  almost  completely  disappeared. 

The  duration  of  the  rheumatic  attack  is  much  longer  in  some  children 
than  in  others.  It  may  be  variously  estimated  according  to  the  method 
upon  which  the  reckoning  is  conducted.  If  we  take  into  account  merely 
the  joint  affection  and  the  general  symptoms,  the  disease  may  be  considered 
over  in  a  few  days.  A  child  may  be  taken  with  high  fever,  and  complain 
of  pain  in  one  or  other  of  his  joints,  which  is  found  to  be  red,  swollen,  and 
tender.  In  twenty-four  or  forty-eight  hotu'S  the  articular  inflammation 
may  be  at  an  end  and  the  temperature  normal.  But  it  does  not  follow 
that  the  disease  is  over  ;  and  if  we  at  once  begin  to  treat  the  child  as  a 
convalescent,  we  may  find  reason  to  regret  our  preciiDitation.  Serious  in- 
flammation of  the  pericardium  and  lining  membrane  of  the  heart  is  quite 
compatible  with  a  normal  temperature  ;  and  these  internal  lesions  may  be 
only  beginning  when  the  external  sigTis  of  the  disease  are  on  the  wane.  As 
it  is  only  in  exceptional  cases  of  rheumatic  fever  that  the  heart  does  not 
suffer,  and  as  the  mildest  attack  of  pericarditis  is  seldom  OA^er  before  a 
week  has  gone  by,  eight  or  ten  days  must  be  considered  the  earliest  period 
at  which  convalescence  can  be  said  to  begin. 

In  other  cases,  if  there  are  frequent  relapses,  the  disease  may  be  pro- 
longed for  many  weeks,  the  inflammation  leaving  joints  and  returning  to 
them  with  wearisome  repetition,  and  the  pericardial  inflammation  waxing 
and  waning  with  similar  persistency.  In  this  way  an  attack  may  be  made 
to  last  six  weeks  or  two  months.  It  is,  however,  only  right  to  say  that 
since  the  introduction  of  the  sahcylates  these  cases  are  much  rarer  than 
they  used  to  be. 

Although  the  joint  affection  in  rheumatism  is  usually  an  acute  disease, 
and  ceases  when  the  attack  is  at  an  end,  yet  this  is  not  always  the  case. 
Children  with  strong  rheumatic  tendencies,  and  who  have  had  several  at- 


ACUTE   RHEUMATISM — DIAGNOSIS.  161 

tacks  of  rheumatic  fever,  may  complain  of  wandering  pains  in  tlie  back, 
neck,  and  loins,  and  of  transient  discomfort  and  stiffness  in  a  joint  from 
time  to  time,  especially  in  the  variable  seasons  of  the  year,  without  having 
to  take  to  their  •  beds.  In  such  patients  there  is  general  impairment  of 
health,  appetite  is  poor,  and  nutrition  is  unsatisfactory.  The  child  is 
often  excessively  nervous,  sleeps  badly  at  night,  and  is  changeable  in  tem- 
per. Dr.  West  has  connected  these  symptoms  with  the  lithic  acid  diathe- 
sis. There  is  no  doubt  that  such  children  are  subject  to  sandy  deposits 
in  their  urine,  and  to  abundant  secretion  of  urea. 

Diagnosis.  —  When  the  joint  affection  is  well  marked  it  can  scarcely 
be  mistaken.  An  acute  articular  inflammation  which  flies  from  joint  to 
joint  capriciously,  is  accompanied  by  redness,  swelling,  and  extreme  ten- 
derness, and  in  a  day  or  a  couple  of  days  has  passed  completely  away 
from  the  joint  first  attacked,  to  run  the  same  rapid  course  in  another — 
such  a  disease  can  only  be  rheumatism.  Real  rheumatic  joint  affections 
are  very  transitory.  If  redness,  pain,  and  swelling  persist  in  a  joint  supposed 
to  be  rheumatic,  we  may  suspect  strongly  that  the  true  cause  of  the  lesion 
has  yet  to  be  discovered.  It  is  often  difficult  to  decide  the  nature  of  the 
obscure  pains  and  stiffnesses  from  which  some  children  suffer.  The  so- 
called  "growing  pains  "  are  often  rheumatic  in  their  origin  ;  and  if  they 
occur  in  children  of  decided  rheumatic  family  tendency,  should  be  re- 
garded with  extreme  suspicion.  A  careful  examination  of  the  chest  will 
often  clear  up  obscurity,  and  it  is  unfortunately  too  common  to  find  serious 
valvular  or  pericardial  mischief  associated  with  a  very  trifling  amount  of 
articular  or  even  muscular  pain  in  young  subjects.  A  to-and-fro  friction 
sound  over  the  precordial  region,  if  decided,  is  very  suspicious  in  itself  of 
pericardial  inflammation.  If  the  child  look  ill,  and  especially  if  there  be 
also  increase  of  the  heart's  dulness,  the  evidence  in  its  favour  is  complete. 
A  faint  double  rub  at  the  base  of  the  heart  is  not  in  itself  sufficient  to  es- 
tabhsh  this  conclusion  ;  for  such  a  friction  may  be  j^roduced  by  slight 
roughness  of  the  pericardial  surface,  from  prominent  vessels  or  other  cause, 
when  the  membrane  is  qiiite  free  from  inflammation. 

Dulness  of  j)yramidal  shape  in  the  praecordial  region,  although  very 
suspicious  of  pericardial  effusion,  is  not  conclusive  ;  such  a  dulness  may  be 
produced  by  a  mass  of  enlarged  glands  in  the  anterior  mediastinum.  Ex- 
tension of  dulness  to  the  left,  beyond  the  point  at  which  the  apex  beats, 
is  said  to  be  a  positive  sign  of  effusion.  The  increase  in  the  dull  area 
when  the  patient  is  placed  in  the  erect  position  is  often  absent ;  when 
present,  it  is,  no  doubt,  an  additional  proof  of  fluid  accumulation  in  the. 
sac  of  the  heart. 

When  the  fluid  becomes  purulent,  as  it  may  do  at  an  early  date,  the- 
nature  of  the  contents  of  the  sac  may  be  inferred  from  the  variable- 
temperatui-e,  the  mei'cury  rising  every  night  to  104°  or  105°,  and  sinking 
in  the  morning  to  the  normal  level,  or  even  below  it ;  the  eai'ly  subsidence 
of  the  friction,  although  the  amount  of  the  effusion  remains  unchanged  ^ 
the  stationary  character  of  the  dulness,  showing  want  of  absorption  of  the 
fluid  ;  and  the  appearance,  after  a  time,  of  more  or  less  general  oedema, 
without  albuminuria. 

On  accoiuit  of  the  frequency  with  which  pericarditis  and  pleurisy  are 
combined  in  young  children,  we  should  never  neglect  to  make  a  careful 
examination  of  the  heart  in  every  case  in  which  we  have  ascertahied  the 
existence  of  pleural  inflammation.  Pericarditis,  under  these  cu-cumstances,. 
is  not  easy  to  detect,  as  the  dulness  in  the  prsecordial  region  is  attributecl 
to  the  effusion  in  the  chest  cavity.     Unless,  however,  the  pleural  effusion 


162  DISEASE   IN   CHILDEEN. 

be  very  great,  the  percussion  note  in  tlie  infra-clavicular  region  is  very 
diiferent  from  tliat  obtained  in  the  prsecordia.  If,  therefore,  we  iind  com- 
plete dulness  towards  the  upjDcr  part  of  the  sternum,  and  a  fairly  resonant 
or  wooden  note  below  the  clavicle  near  the  acromial  angle,  we  may  strongly 
suspect  accumulation  in  the  pericardial  sac.  Friction  over  the  heart  may 
then  be  generally  heard  on  careful  auscultation. 

A  difficulty  sometimes  arises  in  these  cases  from  a  pleural  friction  of 
cardiac  rhythm  being  heard  at  the  Hmits  of  the  pericardium.  This  is  owing 
to  the  action  of  the  heart  causing  a  movement  between  the  adjacent  pleural 
surfaces.  In  these  cases  if  the  child  be  old  enough,  or  sufficiently  amia- 
ble, to  follow  directions,  we  should  listen  at  the  seat  of  friction  while  the 
breath  is  held  after  forced  expiration,  and  if  the  rub  cease  or  be  heard 
only  at  this  spot,  it  is  probably  due  to  the  cause  refen-ed  to.  It  is  not 
alwa^'S  jDossilile,  however,  positively  to  exclude  pericarditis. 

If  we  hear  a  blowing  murmur  at  the  apex  of  the  heart,  the  question  of 
valvular  competence  has  to  be  considered.  All  blowing  murmurs  at  the 
apex  must  not  be  taken  to  indicate  regurgitation,  nor,  indeed,  are  they  a 
positive  sign  that  the  endocardium  is  inflamed  at  all.  The  mui'mur  may 
be  the  consequence  of  regurgitation,  of  roughness  of  the  valve  or  cardiac 
lining,  of  ansemic  dilatation  of  the  ventricle,  or  of  mere  abnoirmal  tension 
•of  a  healthy  valve,  and  there  is  nothing  in  the  quality  of  the  sound  to  show 
to  which  of  these  causes  it  may  be  properly  assigned.  If,  however,  the 
second  sound  is  evidently  intensified  over  the  pulmonary  artery ;  if  the 
murmur  is  heard  at  the  angle  of  the  scapula  ;  and  if,  with  a  full  contrac- 
tion of  the  left  ventricle,  the  pulse  is  feeble,  small,  and  irregular,  we  may 
confidently  pronounce  the  mitral  valve  to  be  insufficient.  Still,  regurgi- 
tation may  take  place  without  giving  rise  to  these  signs.  Therefore,  in 
most  cases  we  must  reserve  a  positive  opinion,  and  wait  until  suffi.cient 
time  has  elapsed  to  allow  of  nutritive  changes  taking  place  in  the  wall  of 
the  heart.  If  there  be  no  displacement  of  the  apex-beat  at  the  end  of 
twelve  months,  we  may  be  satisfied  that  the  cause  of  the  murmur  is  not 
regurgitation. 

A  recent  murmm-  is  very  soft  in  quality  and  of  low  pitch.  After  being 
in  existence  for  some  months  it  becomes  harsher  and  its  pitch  rises.  If  in 
a  case  of  acute  rheumatism  we  hear  a  harsh  and  loud  endocardial  murmur 
at  the  apex,  we  may  be  sure,  whatever  its  mechanism,  that  it  is  not  of  re- 
cent origin,  but  is  a  reUc  of  some  former  attack. 

The  diagnosis  of  ulcerative  endocarditis  has  been  already  sufficiently  ex- 
plained. If  we  find  that  a  child,  who  has  lately  suffered  from  an  attack  of 
acute  rheumatism  with  endocarditis,  remains  feverish,  with  rapid  elevations 
and  depressions  of  temperature,  such  as  are  characteristic  of  suppuration  ; 
if  he  pass  quickly  into  a  typhoid  state  with  dry  brown  tong-ue,  loss  of  ap- 
petite, hurried  breathing,  and  signs  of  great  prostration,  we  should  sus- 
pect the  presence  of  this  complication ;  and  if  we  find  evidence  of  embol- 
isms in  special  organs,  our  suspicions  are  sufficiently  confirmed. 

Prognosis. — The  immediate  prognosis  of  acute  rheumatism  is  seldom 
otherwise  than  favourable.  Even  the  existence  of  endocarditis  and  inflam- 
mation of  the  pericardium  cannot  often  be  regarded  as  giving  rise  to  any 
fear  of  immediate  danger.  Still,  it  is  weU  not  to  speak  too  positively  in 
predicting  a  favourable  issue  to  the  illness.  In  acute  rheumatism—  even  in 
the  mildest  cases — there  is  a  tendency  to  hyperinosis  ;  and  the  rapid  for- 
mation of  a  clot  in  the  right  ventricle  of  the  heart  or  in  the  pulmonary 
artery  may  be  a  cause  of  sudden  death.  In  some  instances  this  distress- 
ing accident  happens  quite  unexpectedly  in  a  case  which  is  running  a  fa- 


ACUTE   EHEUMATISM — PROGNOSIS — TPwEATMENT.  163 

vourable  course,  and  may  even  occur  at  a  late  period  of  the  disease  after 
convalescence  has  seemed  to  be  established.  Again,  in  rare  cases,  pericar- 
ditis is  a  cause  of  death.  When  the  effused  fluid  is  or  becomes  purulent, 
the  danger  is  great ;  and  feAV  such  cases  recover. 

The  ultimate  consequences  of  an  attack  of  rheumatic  fever  may  be  very 
serious,  for  the  large  majority  of  cases  of  heart  disease  can  be  referred  to 
this  cause.  But,  as  ah'eady  remarked,  the  mechanism  of  heart-murmurs 
is  so  various,  that  the  mere  existence  of  a  blowing  sound  at  the  apex  of 
the  heart  is  no  indication  in  itself  that  serious  consequences  are  to  be  ap- 
prehended. If  the  child  be  seen  during  an  attack,  or  while  the  murmur 
is  still  recent,  it  is  impossible  to  speak  with  certainty  as  to  the  gravity  to 
be  attached  to  the  phenomenon.  If,  after  a  time,  we  discover  signs  of  di- 
lated hypertroj)hy  of  either  ventricle,  with  displacement  of  the  heart's 
apex,  and  accentuation  of  the  second  sound  at  the  pulmonary  cartilage, 
we  may  positively  assume  that  serious  incompetence  exists  of  the  mitral 
valve. 

Endocardial  mm-murs  arising  during  an  attack  of  rheumatism  in  chil- 
dren sometimes  disappear.  It  is  probable  that  in  all  these  cases  the  mor- 
bid sound  was  generated  by  other  mechanism  than  valvular  incompetence, 
for  I  have  never  known  the  auscultatory  sounds  to  become  healthy  except 
in  cases  where  the  heart's  apex  has  retained  its  normal  situation. 

A  little  boy,  aged  eighteen  months,  with  sixteen  teeth,  was  brought  to 
me  in  November,  1874.  A  few  months  previously  he  had  seemed  to  have 
pain  and  stiffness  in  some  of  his  joints,  and  had  been  a  little  feverish. 
Since  that  time  he  had  been  subject  to  palpitations  which  were  sometimes 
violent.  On  examination  I  found  a  loud  basic  systolic  murmur  conducted 
to  the  second  right  cartilage,  and  at  the  apex  a  less  loud  mitral  mur- 
mur. The  apex-beat  was  normal.  In  March,  1875,  I  saw  the  child  again. 
The  apex-beat  was  still  in  normal  site.  The  heart-sounds  were  a  little 
muffled  to  the  ear,  although  no  murmur  could  be  heard  at  either  the  base 
or  the  apex  ;  but  on  this  occasion  no  attempt  was  made  to  excite  the  heart's 
action.  The  patient  was  seen  for  the  third  time  in  March,  1881.  He  was 
now  nearly  eight  years  old,  and  of  average  height  for  that  age.  Although 
rather  thin,  he  was  stated  to  enjoy  good  health,  and  never  complained  of 
palpitations  or  of  breathlessness.  The  position  of  the  apex-beat  remained 
unaltered.  The  first  sound  was  muffled,  and  after  the  boy  had  been  made 
to  run  round  the  room,  a  faint  systolic  murmur  was  developed  at  the  apex. 
It  could  not  be  heard  at  the  angle  of  the  scapula. 

In  this  case  the  basic  murmur  disappeared,  and  that  at  the  apex  be- 
came so  indistinct  that  it  could  only  be  detected  by  exciting  the  heart's 
action.  Whatever  may  have  been  the  cause  of  the  abnormal  sounds  first 
heard,  they  were  apparently  the  consequence  of  rheumatism.  Still,  it 
seems  certain  that  there  could  have  been  no  organic  lesion  of  valve,  for  in 
the  course  of  nearly  seven  years  no  alteration  in  the  nutrition  of  the  heart 
had  taken  place. 

Treatment. — A  child  the  subject  of  acute  rheumatism  must  be  kept  in 
bed  ;  the  inflamed  joints  must  be  wrapped  in  cotton  wool,  kept  in  place  by 
a  firmly  applied  flannel  bandage  ;  and  the  chest  should  be  also  enveloped 
in  the  same  material.  A  mercurial  pin-ge  should  be  given  to  produce  free 
action  of  the  bowels  ;  and  saHcylate  of  soda  should  be  administered  with- 
out unnecessary  delay.  Children,  as  a  rule,  bear  this  remedy  well.  It  is 
exceptional  to  find  any  ill  effects  resulting  from  its  employment.  For  a 
child  of  five  years  old,  ten  grains  of  the  salt  may  be  given  eveiy  two  or 
three  hours   with   tincture  of  orange   peel   and    glycerine.     Within   two 


164  DISEASE  IN   CHILDEEN". 

or  three  days,  sometimes  within  a  few  hours  of  beginning  the  treatment,, 
the  temperature  falls,  the  pulse  becomes  less  frequent,  and  the  joint  symp- 
toms are  moderated.  The  pulse  usually  loses  in  strength  as  well  as  in 
frequency  ;  and  the  depression  induced  by  the  action  of  the  drug  upon 
the  muscular  fibres  of  the  heart  is  sometimes  so  great  that  its  administra- 
tion has  to  be  supj)lemented  by  the  free  use  of  stimulants.  This  effect  of 
the  remedy  is,  however,  less  common  in  children  than  it  is  in  the  adult, 
and  I  have  rarely  been  obliged  to  discontinue  its  use  for  this  reason.  It 
sometimes  causes  distressing  vomiting,  and  occasionally  excites  epistaxis 
which  may  be  obstinate.  If,  on  account  of  any  of  these  accidents  the 
treatment  has  to  be  suspended  before  the  disease  is  completely  subdued, 
the  temperature  often  rises  again,  and  the  joint  affection  may  return. 

In  a  small  minority  of  the  cases  the  medicine,  although  well  borne,  ap- 
pears to  exercise  no  influence  upon  the  disease,  and  even  when  it  lowers 
the  temperature  and  subdues  the  joint  affection,  it  seldom  prevents  the  oc- 
currence of  cardiac  or  pleural  inflammation.  The  first  signs  of  pericar- 
ditis may  be  noticed  when  the  patient  appears  to  be  under  the  influence 
of  the  remedy  ;  and  I  cannot  say  that  in  any  case  the  course  of  the  peri- 
cardial disease  has  appeared  to  me  to  be  shortened  by  the  use  of  the  sali- 
cylate. Still,  if  only  for  its  influence  in  reducing  temperature  and  check- 
ing articular  inflammation,  the  drug  would  be  a  most  valuable  one,  and  we 
should  not  be  doing  our  duty  to  the  patient  if  we  neglected  to  employ  it. 

In  cases  where  the  sahcylate  cannot  be  used,  we  may  adopt  the  alkaline 
treatment,  giving  bicarbonate  of  jDotash  in  ten-grain  doses  every  three  or 
four  hours.  If  thought  advisable,  the  bicarbonate  may  be  combined  with 
quinine  ;  or  we  may  prescribe  a  mixture  of  quinine  with  iodide  of  potas- 
sium, as  recommended  by  Dr.  Greenhow.  The  objection  to  the  alkaline 
plan  of  treatment  is  that  it  encourages  the  tending  to  anaemia.  It  should 
therefore  be  supplemented  by  the  early  administration  of  iron  when  the 
joint  pains  have  subsided.  The  method  of  treatment  advocated  by  Dr. 
H.  Davis,  which  consists  in  encircling  the  affected  joint  with  a  thin  line  of 
blistering  fluid  is  a  painful  proceeding  and  ill-suited  to  young  patients. 
The  best  local  application  is  a  thick  layer  of  cotton  wool,  with  a  firmly  ap- 
plied flannel  binder. 

If  there  be  much  pain  in  the  joints,  a  small  dose  of  Dover's  powder  can 
be  given  at  night  (gr.  ij.-iij.  to  a  child  of  four  or  five  years  old).  Chloral 
must  not  be  used  during  the  administration  of  the  salicylate,  as  it  also  has 
a  depressing  effect  uj)on  the  heart. 

Hyperpyrexia  is  not  common  in  cases  of  rheumatic  fever  in  children, 
and,  indeed,  it  is  difficult  to  say  what  degree  of  elevation  of  temperature  can 
in  an  ordinary  case  be  accounted  hyperpyrexia  in  a  child.  An  injurious  > 
amount  of  fever  is  usually  accompanied  by  symptoms  of  mental  disturb- 
ance such  as  are  characteristic  of  the  so-called  "  cerebral  rheumatism." 
If  these  are  absent,  it  is  unnecessary  to  attempt  to  reduce  the  temperature 
by  baths ;  unless,  indeed,  the  pyrexia  persist  and  seem  to  be  injuriously 
affecting  the  patient's  strength.  I  have  never  seen  a  case  of  rheumatic  fe- 
ver in  a  child  in  which  I  have  felt  it  necessar}'  to  employ  cold. 

The  diet  in  acute  rheumatism  must  be  simple.  While  the  fever  per- 
sists the  child  should  take  nothing  but  milk  and  fresh-meat  broths,  with  a 
little  dry  toast.  "When  the  temperature  falls,  a  more  generous  diet  may 
be  allowed  ;  but  for  some  time  attention  should  be  paid  to  the  quantity  of 
fermentable  matter,  such  as  starches  and  sweets,  taken  by  the  child.  The 
appearance  of  lithates  in  his  water  is  a  sure  sign  that  some  modification  in 
his  diet  is  required. 


ACUTE   EHEUMATISM — TEEATMENT.  165 

Directly  the  existence  of  pericarditis  is  ascertained,  a  blister  should  be 
applied  over  the  prsecordial  region  without  loss  of  time.  I  prefer  the 
blistering  fluid  for  this  purpose  as  most  certain  in  its  action,  and  use  it 
to  quite  young  children.  It  is  of  extreme  importance  to  check  the  peri- 
cardial inflammation  early,  and  there  are  no  means  at  our  command  so 
■efficacious  for  this  purpose  as  a  blister.  In  many  cases  the  effusion  begins 
to  disappear  as  the  blister  rises.  If  there  be  much  effusion,  and  the  joint 
affection  have  subsided,  I  am  in  the  habit  of  giving  large  doses  of  the  io- 
dide of  potassium,  alone,  or  with  the  tartrate  of  iron.  The  iodide  is  in 
my  opinion  of  great  value  in  removing  serous  effusions,  if  given  in  full 
doses.  To  a  child  of  five  or  six  years  of  age  I  give  ten  grains  of  the  io- 
dide three  times  a  day,  and  have  never  seen  ill  effects  follow  its  employ- 
ment. On  the  contrary,  its  value  in  causing  absorption  and  restoring  the 
natural  state  of  the  membrane  has  appeared  to  me  to  be  very  decided. 

In  endocarditis,  also,  blistering  should  be  employed ;  and  if  the  tem- 
perature has  fallen,  iron  and  quinine  should  be  prescribed.  The  same 
tonic  treatment  can  be  adopted  in  cases  of  pericarditis  after  absorption  of 
the  effusion,  for  the  patient  is  usually  left  anaemic  and  weak  from  the  at- 
tack, especially  if  he  have  been  treated  with  the  salicylate  of  soda.  In  all 
cases  where  the  disease  has  been  complicated  with  endocarditis  it  is  ad- 
visable to  keep  the  child  in  bed  as  long  as  possible  ;  and  even  when  he  is  al- 
lowed to  get  up  it  is  wise  to  enforce  the  utmost  attainable  quiet.  In  these 
cases  the  heart  is  more  likely  to  recover  itself  if  its  action  be  not  excited  ; 
and,  indeed,  judicious  care  during  convalescence  may  largely  influence  the 
future  well-being  of  the  patient.  Complete  rest  moderates  the  heart's  ac- 
tion, and  allows  time  for  the  healthy  removal  of  inflammatory  products  from 
the  valves.  If  such  products  become  organized,  they  contract  the  tissues 
and  cause  puckering  of  the  valves,  with  aU  the  evils  which  the  resulting 
hindrance  to  the  circtdation  must  inevitably  entail. 

If  suppuration  in  the  pericardium  is  suspected,  the  sac  should  be  care- 
fvdly  punctured  with  a  hypodermic  syringe  in  the  fourth  or  fifth  interspace, 
near  the  left  edge  of  the  sternum,  to  make  sure  that  the  fluid  is  purulent. 
If  it  prove  to  be  so,  the  question  of  evacuating  the  contents  of  the  peri- 
cardium must  be  considered.  Professor  Rosenstein  has  reported  an  interest- 
ing case,  in  a  boy  of  ten  years  of  age,  in  whom  recovery  took  place  after  the 
sac  had  been  emptied.  The  pericardium  was  opened  by  incision  in  the 
fourth  space,  near  the  sternum,  and  after  the  pus  had  escaped,  two  drain- 
age-tubes were  passed  into  the  wound,  and  antiseptic  dressings  were  em- 
ployed. This  form  of  pericarditis  is  so  fatal  that  the  operation  should  be 
decided  upon  if  the  state  of  the  patient  offer  the  slightest  prospect  of  its 
success. 

Muscular  rheumatism,  whether  it  affects  the  abdominal  wall  or  the 
muscles  of  the  neck,  must  be  treated  with  stimulating  applications  and 
with  warmth.     A  good  mercui-ial  purge  to  relieve  the  bowels  is  useful. 

In  cases  of  chronic  joint  pains  affecting  children  who  are  old  sufferers 
from  rheumatism,  it  will  be  often  necessary  to  change  the  conditions  under 
which  the  patient  has  been  living.  Removal  to  a  warm  dry  air  will  often 
do  wonders.  Great  attention  should  be  paid  to  the  action  of  the  skin  and 
kidneys.  Five  or  six  grains  of  bicarbonate  of  potash,  with  an  equal  quan- 
tity of  citrate  of  iron,  given  three  times  a  day,  will  be  found  of  service. 
Fermentable  matters  and  acid-making  articles  of  diet  should  be  taken  with 
moderation. 


CHAPTER  IV. 

SPONTANEOUS  GANGEENE. 

Amongst  the  non-infectious  general  diseases  may  be  included  the  curious 
condition  in  which  apparently  spontaneous  gangrene  becomes  developed 
in  various  parts  of  the  body.  The  lesions  are  often  s^Tametrical,  but  are 
not  so  in  every  case.  Sometimes  the  lower  limbs  are  the  parts  affected  ; 
but  portions  of  the  face  and  trunk  may  be  also  attacked.  Children,  the 
subjects  of  this  tendency,  are  not  always  cachectic  or  otherwise  enfeebled ; 
although  in  many  cases  the  gangrenous  process  occurs  in  convalescents 
from  acute  or  depressing  disease.  After  measles  a  special  disposition  to 
gangTene  is  occasionally  discovered.  The  same  tendency  is  displayed,  but 
less  frequently,  after  other  acute  specific  diseases,  as  scarlatina,  variola, 
varicella,  and  enteric  fever  ;  and  insanitary  conditions  generally,  combined 
with  poor  food,  have  been  cited  as  predisposing  causes  of  the  gangrenous 
lesions.  It  is  said  to  be  more  common  in  cold  than  in  warm  weather  ;  and 
some  observers  are  disposed  to  look  upon  a  low  temperature  of  the  au'  as 
one  of  the  causes  of  the  mischief. 

In  the  case  where  the  disease  ap^Dcars  in  a  weU-nourished  child  who  has 
not  previously  been  subject  to  any  enfeebhng  influence,  the  etiology  of  the 
lesion  is  obscure.  Eaynaud,  who  was  the  first  to  describe  a  "  symmetrical 
gangi-ene  of  the  extremities,"  attributes  the  affection  to  a  spasm  of  the  ar- 
terioles, followed  by  a  migration  of  blood-corpuscles  and  transudation  into 
the  skin.  He  states  that  he  has  noticed,  with  the  oj)hthalmoscope,  spasm 
of  the  arterioles  of  the  fundus  occuli  in  these  cases.  The  disease  is  some- 
times associated  mth  intermittent  htematuria ;  and  Dr.  Gee  has  reported 
the  case  of  a  little  girl,  aged  five  years,  in  whom  gangrene  of  the  vulva  was 
combined  with  embolism  of  the  kidney  and  the  brain.  Still,  in  many  cases 
no  lesion  of  the  -s^scera  or  arterial  system  is  discoverable  on  the  closest  in- 
vestigation ;  and  no  CAadence  has  yet  been  brought  forward  pointing  to 
any  centric  or  nervous  defect  capable  of  exciting  mortification  of  the  tis- 
sues, although  the  symmetrical  distribution  of  the  lesions  is  suggestive  in 
many  cases  of  some 'such  mode  of  origin.  Dr.  Nedop»il,  in  explaining -the 
mechanism  by  which  spontaneous  gangrene  is  produced,  assumes  the  ex- 
istence of  a  '^fimctional  neiwous  derangement.  This  writer  agrees  "^"ith 
Eaynaud  in  ascribing  the  arrest  of  circulation  to  a  spasm  of  the  waUs  of 
the  arterioles  in  the  part  affected.  He  supposes  that  ovdug  to  ii'ritation  of 
sensory  and  centripetal  nerves  the  reflex  centre  of  the  vaso-constrictors 
which  control  the  cu'culation  at  the  extremities  of  the  limbs  is  excited.  If 
the  spasm  be  prolonged  and  be  sufficiently  intense  to  close  the  arterial 
channels,  gangrene  of  the  pai't  may  be  induced. 

Children  of  all  ages  may  suffer  from  the  disease.  It  may  occur  imme- 
diately after  birth,  or  may  appear  in  later  childhood.  It  is  not  always 
fatal ;  but  if  the  gangrene  is  extensive  and  penetrates  deeply  through  the 
skin,  it  seldom  terminates  otherwise  than  unfavourably. 


SPONTANEOUS    GANGEENE — MORBID   ANATOMY — SYMPTOMS.     167 

Gangrene  as  it  affects  the  moutli  and  the  king  is  described  elsewhere.. 
In  the  present  chapter  gangrene  of  the  skin  and  underlying  tissues  will 
alone  be  considered. 

Morbid  Anatomy. — ^Gangrene  may  affect  the  healthy  skin  or  may  attack 
a  blistered  surface.  In  the  first  case  the  skin  becomes  dark  blue  in  colour, 
and  then  almost  black.  Its  consistence  varies.  Sometimes  it  is  hardened 
and  feels  dry  like  parchment ;  in  others  it  is  softer  and  moist.  At  the  mar- 
gins of  the  gangrenous  patch  the  skin  is  reddened  and  inflamed.  Instead 
of  blackened  patches  the  gangrene  may  assume  the  form  of  ulcers  limited 
in  extent.  These  ulcers  are  circular  in  shape,  with  abrupt,  clean-cut  edges, 
and  their  depressed  floor  is  formed  of  a  gray  or  blackish  slough.  They 
may  penetrate  completely  through  the  skin. 

When  gangrene  attacks  a  blistered  surface  the  lesion  is  usually  more 
superficial  than  in  the  former  case.  It  appears  in  the  form  of  a  lightish 
gray  slough,  marbled  here  and  there  with  a  violet  tint. 

Sometimes  the  gangrene  penetrates  completely  through  the  skin  and 
subcutaneous  tissues.  It  may  then  be  found  in  two  forms  :  a  moist  and  a 
dry  variety.  In  the  moist  form  the  gangrenous  patch  is  black,  softened, 
and  infiltrated  with  a  dirty,  reddish  fluid.  Its  odour  is  excessively  offensive, 
and  the  tissues  affected  appear  to  be  completely  converted  into  a  putres- 
cent pulp.  Often  it  begins  as  a  small  pimple,  which  changes  into  a  bleb 
containing  thin  purulent  matter.  As  the  process  continues,  more  and 
more  skin  becomes  involved,  and  a  considerable  extent  of  surface  may  be 
red,  oedematous,  and  boggy  to  the  touch.  The  centre  is  usually  purple. 
On  this  surface  blebs  form  and  burst,  leaving  spots  of  gangrene.  The 
sloughs  unite,  and  if  the  j^atient  survive  may  become  limited.  The  gan- 
grenous part  is  then  thrown  off,  leaving  the  under  muscles  exposed. 

When  the  gangrene  assumes  the  dry  form  its  anatomical  characters  are 
similar  to  those  of  senile  gangrene.  MM.  Rilliet  and  Barthez  describe  a 
case  in  which  the  skin  of  one  leg  was  completely  mortified.  On  the  toes 
it  was  slirivelled  and  blackish.  Elsewhere  it  was  transparent,  hard,  red- 
dish, and  elastic  like  a  piece  of  parchment.  The  dried  skin  was  so  trans- 
parent that  the  injected  venous  radicles  could  be  seen  ramifying  on  the 
under  surface,  and  it  had  a  curious  resemblance  to  the  rind  of  bacon. 

In  some  cases  ante-mortem  clots  have  been  found  in  the  arteries  lead- 
ing to  the  affected  part ;  but  in  not  a  few  cases  no  embolus  is  to  be  found 
in  the  femoral  or  other  arteries  of  the  diseased  Hmb. 

A  common  seat  for  this  spontaneous  gangrene  is  the  vulva  in  the  fe- 
male child.  Here  the  gangrene  usually  begins  on  the  labia,  and  may 
spread  thence  to  the  interior  of  the  vulva,  to  the  anus  and.  the  sacrum.  The 
affected  parts  are  dry  and  blackish-brown,  and  may  slough  off,  leaving  the 
muscles  exposed.  In  male  infants  the  scrotum  is  sometimes  attacked. 
Often  the  patches  of  gangrene  are  not  limited  to  one  region  or  to  one 
limb,  but  occur  in  scattered  spots  of  various  sizes  situated  on  the  legs, 
the  arms,  the  buttocks,  or  other  parts  of  the  body.  The  lesions  are  then 
often  symmetrical,  attacking  corresponding  parts  of  the  surface  on  the  two 
sides. 

Symptoms. — Children  the  subjects  of  this  tendency  to  spontaneous 
mortification  are  liable  to  attacks  of  what  has  been  called  "local  asphyxia." 
Some  part  of  the  body — usually  a  finger,  a  toe,  or  the  whole  of  a  hand,  a 
foot,  or  even  a  limb — becomes  excessively  painful,  and  is  noticed  to  be 
purple  in  colour.  It  feels  cold  to  the  touch.  The  tint  may  deepen  to  a 
dull  leaden  hue.  After  three  or  four  hours,  during  which  the  greatest 
anxiety  has  been  excited,  the  pain  subsides  ;  the  colour  of  the  part  grows 


168  DISEASE  IE"   CHILDEElSr. 

lighter  and  tlien  becomes  normal,  and  the  natural  warmtli  returns  to  the 
skin.  These  attacks  are  sometimes  accompanied  by  severe  abdominal 
pain.  Occasionally,  too,  they  are  followed  by  haematuria  of  a  distinctly 
intermittent  character,  the  water  being  normal  at  some  times,  red  with 
blood  at  others.  The  attacks  of  local  asphyxia  do  not  always  subside 
harmlessly.  In  some  cases  the  symptoms  grow  slowly  worse,  and  the  af- 
fected part  becomes  gangrenous. 

Grangrene  occurs  in  two  principal  forms  :  disseminated  and  more  or 
less  symmetrical  gangTene,  and  gangTene  limited  to  the  extremities,  the 
vulva,  or  the  scrotum. 

In  the  disseminated  variety  the  disease  begins  in  scattered  nodules  or 
patches.  The  child  for  some  days  appears  to  be  unusually  di-owsy,  and 
then,  if  old  enough  to  speak,  complains  of  pain  in  some  part  of  the  body — 
the  thighs,  legs,  buttocks,  or  arms — and  livid  patches  make  their  appear- 
ance, which  grow  rapidly  darker  in  colour.  The  patches  are  hard  and 
tough  to  the  touch,  and  seem  to  be  tender,  for  pressure  ehcits  signs  of 
suffering.  If  the  patches  are  few  and  small,  the  general  health  may  be 
httle  affected  ;  but  if  they  are  large  or  numerous,  there  may  be  vomiting, 
headache,  and  general  malaise. 

Dr.  Southey  has  reported  the  case  of  a  little  girl,  two  and  half  years  of 
age,  who  had  a  feverish  attack  accompanied  by  pm-puric  spots  on  the 
limbs.  She  soon  recovered,  but  some  months  afterwards  had  a  second  at- 
tack which  lasted  three  days.  About  a  fortnight  later  the  child  complained 
of  headache,  and  said  she  had  hui't  her  legs.  The  pain  was  increased  by 
friction  of  the  limbs.  In  rubbing  them  it  was  noticed  that  the  skin  on 
the  backs  of  the  calves  was  livid.  Soon  afterwards  the  child  vomited,  com- 
plained of  headache,  and  was  feverish.  Towards  the  evening  the  patches 
were  seen  to  have  extended  up  and  down  the  calves  and  to  be  darker  in 
colour.  A  similar  appearance  was  noticed  at  the  backs  of  the  arms,  and 
on  the  following  morning  the  buttocks  had  become  livid. 

"When  admitted  into  the  hospital  on  the  second  day  the  child  was  mori- 
bund. The  pulse  at  the  wrist  was  feeble  and  somewhat  TNTi'y,  but  could 
stiU  be  counted.  The  tibial  pulse  could  not  be  detected.  The  patches  of 
Hvidit}^  felt  hard  and  tough.  The  lungs  and  heart  appeared  to  be  quite 
healthy.  Brandy  and  milk  were  given,  and  two  doses  of  nitro-giycerine, 
but  all  were  vomited.  Intelhgence  was  preserved  until  evening.  Convul- 
sions then  occurred,  and  were  fi-equently  repeated  until  the  child's  death  at 
11  P.M.  The  illness  altogether  lasted  onl}^  thirij'-two  hours.  A  post- 
mortem examination  of  the  body  discovered  no  coarse  lesion  of  the  viscera, 
nor  could  any  embolus  be  detected  in  the  femoral  or  other  arteries  of  the 
left  lower  Hmb,  which  was  the  only  one  examined. 

Mx.  Astley  Bloxam  has  kindly  communicated  to  me  the  particulars  of  a 
case  of  spontaneous  gangrene  which  was  under  his  care  in  the  Chaiing 
Cross  Hospital.  The  child — a  httle  gii-1  of  ten  months  old — had  been  ail- 
ing for  eight  weeks.  A  small  pimjole  then  ajDpeared  on  the  region  of  the 
inferior  angle  of  tlie  scapula.  The  next  day  a  head  formed  on  the  pimple, 
and  became  filled  with  puralent  fluid.  "When  the  child  was  admitted  a 
day  or  two  afterwards  (on  AugTist  19th)  she  was  seen  to  be  pale  and  thin, 
and  was  said  to  be  wasting.  The  whole  of  the  scaj)ular  region  on  the  right 
side  was  oedematous,  red,  bogoy,  and  hot.  In  the  centre  was  a  iDurpuric 
patch  an  inch  and  a  half  long  by  thi-ee-quarters  of  an  inch  broad,  tbe  bor- 
ders of  which  were  quite  purple.  On  palpation  the  patch  gave  a  boggy 
sensation  to  the  finger,  as  if  from  fluid  underneath  the  skin.  The  tempera- 
ture on  the  first  evening  was  101.8°. 


SPONTANEOUS   GANGRENE — VAEIETIES.  169 

On  August  20tli  the  patch  had  slightly  enlarged.  Temperature  :  in  the 
morning,  100.6°;  in  the  evening,  101.2°.     Pulse,  96  ;  respirations,  60, 

On  August  21st  the  patch  was  much  larger,  measuring  three  and  three- 
quarter  inches  long  by  two  and  one-half  inches  broad.  Some  bullse  had 
appeared  on  the  siirface,  and  one  of  these  had  burst,  leaving  a  small  slough. 
There  was  no  tenderness  at  the  gangrenous  part ;  indeed  the  opposite 
appeared  to  be  the  case,  and  the  part  seemed  to  be  unusually  devoid  of  sen- 
sibility. Temperature  :  in  the  morning,  98°;  in  the  evening,  99.6°.  Pulse, 
120  ;  respirations,  60.  An  ammonia  and  bark  mixture  was  ordered,  and  in 
the  evening  the  part  was  well  painted  with  strong  nitric  acid.  The  applica- 
tion caused  no  pain.  Thirty  drops  of  brandy  were  ordered  every  three 
hours. 

After  this  the  slough  did  not  further  increase.  On  the  contrary,  it  be- 
gan to  separate,  and  the  surrounding  oedema  to  subside.  There  was  a  little 
diarrhoea.  On  August  24th  part  of  the  slough  came  away  and  exposed  the 
muscles.  The  child  became  very  fretful  and  weak,  and  died  rather  sud- 
denly on  August  29th. 

When  the  gangi-ene  attacks  the  extremities,  it  may  be  seen  in  the  fingers 
and  toes,  or  may  spread  to  the  hands  and  feet,  or  even  higher  up  in  the 
limb.  Children  so  affected  are  usually  pale,  under-nourished,  and  cachectic 
in  appearance.  After  a  few  days  of  more  or  less  irritability,  loss  of  appetite, 
headache,  sleepiness,  and  geaeral  malaise,  the  patient  begins  to  complain 
of  severe  pains  in  the  toes,  which  may  extend  for  some  distance  up  the  legs. 
At  the  same  time  the  ends  of  the  toes  are  noticed  to  be  dull  red  or  purple, 
and  their  sensibility  is  found  to  be  blunted.  The  pains  continue.  There 
may  be  some  fever  at  night,  and  in  the  morning  the  lividity  of  the  ends  of 
the  toes  is  seen  to  have  extended  to  the  circumference  of  the  nail.  At  this 
point  the  symptoms  may  subside,  the  pains  becoming  moderate,  and  the 
lividity  fading  and  disappearing  ;  or,  on  the  contrary,  the  disease  may  go 
on  to  complete  sphacelus,  and  extend  to  the  whole  of  the  foot  or  even  of 
the  limb.  Thus,  Franyois  records  the  case  of  a  child,  three  years  of  age, 
in  whom  the  gangrene  involved  the  whole  of  the  foot  and  lower  part  of  the 
leo". 

This  form  of  gangrene  may  be  dry  or  moist.  If  the  former,  it  assumes 
the  characters  of  senile  gangrene,  becoming  separated  by  a  line  of  demar- 
cation, and  subsequently  detached.  Raynaud  reports  the  case  of  a  httle 
girl,  aged  eight  years,  of  good  constitution  and  healthy  appearance,  who 
began  to  complain  of  severe  pains  in  the  feet  and  lower  halves  of  the  legs. 
At  the  same  time  the  ends  of  the  toes  were  noticed  to  be  blue.  The  pains 
increased  and  the  child  was  a  little  feverish.  The  fourth  toe  on  each  foot 
became  slate-coloured,  and  the  other  toes  showed  spots  of  livid  red.  The 
mortified  parts  were  insensible  to  the  touch,  but  the  pains  continued  and 
were  worse  at  night.  The  appetite  remained  good,  and  there  was  no  diar- 
rhoea. After  a  few  days  the  pains  ceased,  and  the  gangrenous  patches  be- 
came limited  by  a  well-defined  line.  In  about  a  fortnight  the  toes  desqua- 
mated. Dry  brown  scabs  became  detached,  and  left  the  skin  beneath  them 
tinted  of  a  pale  violet  colour.  On  the  fourth  toe  of  the  right  foot,  the  one 
which  had  exhibited  the  largest  patch  of  gangrene,  a  black  crust  was  thrown 
off,  and  a  suppurating  surface  was  left  which  quickly  healed. 

A  very  similar  case  has  been  published  by  Dr.  Southey.  In  this  the 
spots  of  gangrene  were  accompanied  by  subcutaneous  mottlings  of  the 
trunk  and  limbs.  These  mottlings  developed  into  a  raised  rash  like  ery- 
thema tuberculatum.  The  eruption  at  first  itched,  then  became  tender 
and  painful,  but  eventually  subsided,  leaving  merely  a  discolouration  of  the 


170  DISEASE  ITT   CHILDREIS'. 

skin.  Recovery  in  such  cases  is  sometimes  followed  hj  an  attack  of  par 
ox^'smal  hfematuria,  in  which  large  quantities  of  crystals  of  oxalate  of  lime 
are  passed  with  the  urine. 

In  the  moist  gangrene  of  the  extremities  the  affected  part — which  is 
commonly  the  end  of  a  finger  or  toe — is  swollen,  and  the  epidermis  is  raised 
up  by  red  serous  effusion.  As  the  destruction  of  ilie  tissues  of  the  part 
proceeds,  the  ai'ticulation  may  be  laid  open.  Sometimes  moist  gangrene 
of  the  extremities  is  combined  with  disseminated  spots  of  a  kind  similar 
to  those  previously  described.  Thus,  MM.  Rilhet  and  Barthez  refer  to  the 
case  of  a  little  gu-1,  aged  four  years,  who  was  under  the  care  of  Legendre. 
In  this  child  moist  gangi'ene  attacked  the  ungual  phalanges  of  the  right 
thumb  and  middle  finger — in  the  latter  lading  open  the  second  articulation 
— and  the  ungual  phalanx  of  the  left  forefinger.  Moreover,  gangrenous 
blebs  fiUed  with  bloody  serum  formed  at  the  back  of  the  shoulder,  in  the 
lower  part  of  the  dorsal  region,  and  in  other  parts  of  the  body.  At  last  a 
double  pneumonia  declared  itself,  and  the  child  died  on  the  ninth  day 
from  the  beginning  of  the  illness. 

When  the  gangTenous  process  attacks  the  vulva,  the  lesion  is  usually 
seen  in  a  cachectic  or  weakly  child,  who  has  lately  passed  through  an  ex- 
hausting illness.  Severe  measles  occurring  in  a  scrofulous  subject  is  some- 
times followed  by  this  dangerous  sequela.  As  in  gangrene  of  other  parts 
the  earliest  symptoms  are  usually  loss  of  a23j)etite,  headache,  and  nausea. 
Then  the  child  complains  of  severe  burning  pains  in  the  genitals  ;  and  a 
light  red  cu'cumscribed  patch  is  seen  on  one  of  the  labia,  often  on  its  inter- 
nal aspect.  Around  it  the  tissues  are  dense  and  swollen  for  some  distance. 
The  patient  cries  frequently  with  the  pain,  and  seems  to  suffer  great  dis- 
tress in  passing  her  water.  After  a  day  or  two  ashy  gTay  spots  apjDear. 
These  are  circumscribed  and  limited  by  a  light  red  ring.  Soon  their 
colour  changes  to  a  dark  brown  or  black,  and  the  gangrene  spreads  to  the 
upper  part  of  the  vulva,  the  perinseum,  and  the  anus.  Often  there  is  a 
purulent,  offensive  discharge  from  the  diseased  surface.  The  general  sj-mp- 
toms  also  become  more  pronounced.  The  pulse  is  small  and  rajoid  ;  the 
features  are  pinched,  and  the  face  is  very  pale.  The  child  lies  moaning  in 
her  bed,  and  complains  of  pains  not  only  in  the  diseased  parts,  but  also  in 
the  hmbs  and  body.  Sometimes  a  watery  diarrhoea  comes  on,  and  in  that 
case  the  child  soon  dies  exhausted.  If  by  energetic  treatment  the  gan- 
grenous process  can  be  arrested  before  it  is  too  late,  the  sloughs  separate, 
the  swelhng  and  darkness  subside,  and  a  granulating  surface  is  left  w^iich 
quickly  heals. 

The  gangTenous  patch  is  sometimes  single  and  of  limited  extent.  Often 
the  case  is  first  seen  when  the  separation  has  partially  occurred,  and  a 
sloughy-looking  ulcer  is  found  on  one  of  the  labia.  Still,  however  small 
the  local  lesion  may  be,  the  general  symptoms  are  severe,  and  on  account 
of  the  exhausted  state  of  the  patient  the  danger  is  very  great.  At  the  be- 
ginning of  the  disease  a  slight  febrile  movement  is  sometimes  noticed,  and 
the  temperature  may  reach  100°  or  101°  ;  but  the  pyrexia  usuaUy  quickly 
subsides,  and  the  temperature  for  the  remainder  of  the  illness  is  below 
the  level  of  health.  Death  in  cases  of  gangrene  may  occur  from  exhaus- 
tion. Sometimes  it  is  ushered  in  by  a  series  of  convulsiA^e  attacks.  In  Dr. 
Gee's  case  of  gangrenous  ulcer  of  the  vulva  an  extensive  embohsm  was 
found  in  the  cerebral  arteries. 

Diagnosis. — The  diagnosis  of  spontaneous  gangrene  in  the  child  pre- 
sents little  difiiculty.  The  only  case  in  which  a  mistake  is  likely  to  be 
made  is  that  in  which  the  disease  attacks  the  extremities  of  the  fing-ers  or 


SPOT^TANEOUS   GAIS'GEETTE — PROGISTOSIS — TEEATMENT.         171 

toes.  In  that  case  the  pricking  pain,  combined  with  the  livid  hue  of  the 
skin,  is  suggestive  of  chilblains ;  and,  indeed,  according  to  Raynaud, 
cases  of  this  variety  of  gangrene  have  been  often  confounded  at  the  begin- 
ning with  this  common  and  insignificant  disease.  In  most  cases  of  gan- 
grene, however,  the  pains  are  far  more  severe,  the  occurrence  of  the  local 
symptoms  is  more  abrupt,  and  several  fingers  and  toes  are  attacked  simul- 
taneously. Moreover,  the  gangrenous  lesion  is  often  found  at  a  season 
when  the  common  chilblain  is  not  usually  suffered  from. 

Prognods. — In  every  case  of  gangrene,  whatever  part  of  the  surface  be 
attacked,  the  prognosis  is  most  unfavourable.  The  patient,  indeed,  does  not 
always  die,  but  instances  of  recovery  are  rare.  If  the  patient  be  a  new- 
born infant,  or  a  child  of  weakly  constitution,  he  may  be  considered  to 
have  still  fewer  chances  of  passing  safely  through  so  formidable  an  illness. 
The  most  favourable  cases  are  those  in  which  the  gangrene  is  of  the  dry 
variety  and  remains  limited  to  a  finger  or  toe.  If  the  gangrenous  process 
appeal's  successively  in  several  parts  of  the  body,  Httle  hope  of  recovery 
can  be  entertained. 

Treatment. — In  all  cases  where  a  cachectic  child  is  attacked  with  gan- 
grene, every  effort  should  be  made  to  supjDort  the  strength  of  the  patient, 
and  improve  the  state  of  his  nutrition.  He  should  be  suppUed  with  as 
much  nourishing  food  as  he  can  digest.  Meat — pounded  if  necessary,  and 
strained  through  a  fine  sieve — eggs,  milk,  weU  cooked  vegetables,  and  a 
judicious  quantity  of  farinaceous  matter  must  form  his  diet.  Stimulants 
are  always  requii-ed,  and  the  child  may  take  half  an  ounce  of  port  wine,  or 
the  St.  Raphael  tannin  wine,  diluted  with  an  equal  proportion  of  water, 
after  each  quantity  of  food. 

If  the  patient  be  an  infant  at  the  breast,  we  should  inquire  if  the  sup^ 
ply  of  milk  is  adequate  to  his  necessities.  If  the  breast  milk  is  poor  and 
insufficient,  additional  food  must  be  given  as  directed  elsewhere  (see  page 
603).  White  wine  whey  is  very  suitable  in  these  cases.  Tonics  are  always 
required.  Quinine  can  be  given  in  full  doses  (two  grains  for  a  child  of 
three  years  old,  three  times  a  day),  or  the  ammonia  and  bark  mixture  can 
be  ordered.  Mr.  Cripps  speaks  highly  of  oioium  given  fi-equently  in  small 
doses. 

In  cases  of  disseminated  moist  gangrene  the  heat  of  the  part  should  be 
maintained  by  hot  applications  ;  and  directly  a  slough  is  noticed  on  the 
surface  its  further  extension  should  be  prevented  by  the  free  apphcation  of 
a  powerful  escharotic.  Strong  nitric  acid  should  be  aiDplied  once  thor- 
oughly, and  the  part  must  be  then  kept  covered  with  hot  poultices.  When 
the  slough  separates,  the  resulting  sore  or  sores  can  be  dressed  with  a 
carbolic-acid  lotion  (five  drops  to  the  ounce  of  water),  or  a  solution  of  bo- 
racic  acid  (twenty  grains  to  the  ounce).  In  all  cases  of  gangrene  of  the 
vulva  this  method  of  treatment  is  useful  ;  and  the  local  measui-es  employed 
in  the  treatment  of  gangrenous  stomatitis  are  equally  serviceable  when 
the  vulva  is  the  part  affected.  Pan'ot  advocates  the  use  of  powder  of 
iodoform,  especially  in  cases  of  gangrene  of  the  ^nilva.  The  ulcers  must 
be  first  carefully  cleaned.  Then  they  must  be  completely  filled  with  the 
powder,  no  part  of  the  raw  surface  being  left  uncovered.  If  the  ulcer  is 
very  moist,  it  ought  to  be  dressed  twice  a  day.  This  method  of  treatment 
is  paialess,  and  is  said  to  arrest  the  progi-ess  of  the  ulcer  in  three  or  four 
days.     At  the  same  time  the  sxuTounding  oedema  rapidly  diminishes. 

When  the  gangrene  is  limited  to  the  extremities,  the  affected  part 
should  be  wrapped  in  cotton  wool,  and  gentle  frictions  with  a  piece  of 
flannel  moistened  with  eau-de-Cologne  are  recommended  by  Raynaud.    This 


172  DISEASE  IlSr   CHILDEEN. 

author  disapproves  of  the  use  of  energetic  local  stimulants,  and  states 
that  he  has  seen  very  disastrous  results  follow  quickly  upon  undue  local 
irritation.  Directly  a  line  of  demarcation  forms,  hot  dry  applications, 
such  as  bags  of  heated  bran  or  sand,  should  be  kept  applied  to  the  seat  of 
the  lesion,  so  as  to  preserve  the  dryness  of  the  tissues  and  hasten  the 
separation  of  the  sphacelated  part.  In  extensive  gangTcne  amputation  has 
been  sometimes  performed,  but  without  saving  the  life  of  the  patient.  In- 
deed MM.  Killiet  and  Barthez  are  of  opinion  that  the  removal  of  the  dis- 
eased member  only  hastens  the  fatal  termination. 


|)art  3. 
THE  DIATHETIC  DISEASES. 


CHAPTER  I. 

SCROFULA. 


The  scrofulous  diathesis  is  one  of  the  most  common  of  the  morbid  types 
of  constitution  which  we  meet  with  in  the  child.  It  is  found  in  all  ranks 
of  life,  and  in  almost  all  parts  of  the  world.  It  is,  however,  especially  fre- 
quent in  the  temperate  zones,  being  far  less  common  in  very  cold  or  in 
tropical  climates.  This  vice  of  constitution  is  often  hereditary,  and  is 
then  handed  down  with  singular  persistence  from  generation  to  genera- 
tion. Sometimes,  indeed,  it  is  seen  to  pass  over  certain  members  of  a 
family,  but  even  those  who  escape  may  not  transmit  complete  immunity  to 
their  offspring. 

A  child  who  has  the  misfortune  to  be  born  with  this  unhappy  predis- 
position is  liable  to  very  widespread  evidences  of  the  constitutional  fault 
with  which  he  is  burdened.  His  skin,  his  mucous  membranes,  his  bones, 
joints,  organs  of  special  sense,  lungs  and  lymphatic  system  are  all  excep- 
tionally sensitive  to  the  ordinary  causes  of  disturbance,  and  may  all  or  any 
of  them  become  the  seat  of  obstinate  derangement  or  even  of  incurable  dis- 
ease. These  manifestations  of  the  constitutional  tendency  usually  take 
place  early,  so  that  scrofula  is  especially  a  disease  of  childhood.  Infants, 
indeed,  are  in  great  measure  exempt  from  its  attacks  ;  but  after  the  third 
year  it  begins  to  be  common,  and  from  that  age  until  the  fourteenth  or  fif- 
teenth year  the  diathesis  is  most  active.  At  puberty  its  energy  sensibly 
abates,  and  strumous  disorders  are  less  and  less  frequently  met  with  as  the 
individual  advances  towards  middle  life. 

Causation. ^One  of  the  most  important  of  the  causes  of  scrofula  is  he- 
reditary influence.  When  the  parents  are  actually  suffering  from  the  ca- 
chexia, or  have  suffered  from  it,  the  child  is  hardly  Hkely  to  escape  a  share 
in  the  constitutional  predisposition  ;  but  when  no  such  manifestation  of 
the  tendency  has  been  seen  in  the  father  or  mother,  there  is  a  hope  that 
by  careful  management  and  attention  to  the  laws  of  health  the  same  freedom 
may  be  extended  to  their  offspring.  But  besides  actual  scrofulous  disease, 
other  debilitating  influences  in  the  parents  maj  determine  the  strumous 
constitution  in   their  children.     Thus,  the  cancerous  and  tubercular  ca- 


174  DISEASE  IK   CHILDEEF. 

cliexise  will  do  this.  Syphilis  in  the  third  generation  is  apt  to  manifest 
itseK  by  scrofulous  disorders  ;  and  age  in  the  father,  or  imperfect  nutri- 
tion in  the  mother  during  her  period  of  gestation,  are  also  held  to  be  deter- 
mining causes  of  a  congenital  tendency  to  strumous  comj^laints.  "WTiether 
mere  nearness  of  relationship  on  the  part  of  the  parents  ■will  exercise  the 
same  influence  is  a  question  which  has  been  often  debated,  and  many 
wi'iters  hold  that  it  can  do  so.  I  do  not  think,  however,'  there  is  any  satis- 
factory- proof  that  such  a  result  can  follow  in  cases 'where  there  is  not 
already  a  tendency  to  scrofula  in  the  family. 

Besides  being  hereditaiy,  the  diathesis,  it  is  commonly  held,  may  be 
acquired  under  conditions  favourable  to  its  development.  It  is  true  that  we 
frequently  see  patients  who  exhibit  all  the  signs  of  a  scrofulous  lesion 
without  any  discoverable  family  history  of  scrofulous  disease  ;  but  it  is  often 
difficult  to  trace  out  hereditary  taints,  especially  when  the  transmitted  ten- 
dency has  been  mild  in  its  manifestations,  or  has  skij^ped  over  one  or  two 
generations.  It  is  more  probable  that  in  such  cases  latent  scrofula  is 
developed  by  debilitating  influences  in  children,  who,  under  more  favoura- 
ble circumstances,  would  have  escaped  altogether. 

The  causes  which  are  thus  capable  of  developing  the  cachexia  in.  chil- 
dren whose  constitutional  tendency  is  comparatively  feeble,  are  all  the 
various  agents  which  impaii'  the  nutrition  of  the  body  by  weakening  diges- 
tion, checking  assimilation,  and  interfering  with  the  escajDe  of  waste  mat- 
ters from  the  system.  Repeated  exposure  to  cold  and  damp  ;  an  habit- 
ual coarse  and  indigestible  diet ;  absence  of  fresh  aii',  and  confinement  to 
close,  ill-ventilated  rooms ;  deprivation  of  sunlight  and  want  of  exercise 
— the  continued  operation  of  these  causes,  if  it  cannot  set  up  the  disease 
where  no  predisposition  exists,  has  at  any  rate  a  j)owerful  influence  in 
exciting  the  cachexia  in  children  who  have  been  born  the  subjects  of  the 
diathesis.  Even  grown  up  persons  exposed  to  such  unhealthy  conditions 
are  often  found  to  become  scrofulous.  Therefore  causes  which  are  capa- 
ble of  reawakening  the  cachexia  in  the  adult,  after  the  age  most  prone  to 
it  has  passed  by,  must  act  with  stUl  greater  energy-  in  the  child.  Certain 
fevers  have  the  power  of  developing  or  re-instating  the  disease  in  suita- 
ble subjects.  Measles  and  whooping-cough  have  a  wonderful  influence  in 
this  respect.  Unmodified  small-pox  used  frequently  to  be  followed  by  ob- 
stinate scrofulous  disorders  ;  and  scarlatina  can  count  the  same  comjDlaints 
amongst  its  sequeL^.  Where  the  j)redisj)osition  is  strong,  it  is  probable 
that  any  disease  of  a  lowering  tendency  may  suffice  to  develop  it. 

Scrofula,  like  other  complaints,  has  been  said  to  have  been  communicated 
by  vaccination  ;  but  that  the  disease  possesses  any  specific  morbid  matter 
which  is  capable  of  being  conveyed  from  one  child  to  another  by  inocula- 
tion is  a  doctrine  which  has  now  been  proved  to  be  destitute  of  any  foun- 
dation. 

Morhid  Anatomy. — The  structural  lesions  induced  by  the  scrofulous 
diathesis  consist  in  various  chronic  inflammations  with  their  consequences. 
These  have  nothing  special  in  their  anatomical  characters  to  distinguish 
them  from  the  same  lesions  occurring  in  non-scrofulous  children.  They 
need  not,  therefore,  be  fui-ther  referred  to  in  this  place. 

The  affection  of  the  lymphatic  glands,  which  is  so  characteristic  a  part  of 
the  disease,  differs  from  the  ordinary  h}-jjerplasia  induced  ia  a  healthy  child 
by  neighbouring  inflammation  in  the  fact  that  the  swelling  does  not  subside 
when  the  mitaht  which  has  given  rise  to  it  has  passed  away,  but  continues 
as  a  chronic  condition.  In  the  case  of  a  healthy  child  the  gland  becomes 
more  vascular,  and  swells  up  by  an  increase  in  its  corpuscular  elements. 


SCROFULA — MOEBID   ANATOMY — SYMPTOMS.  175 

These  rapidly  increase,  multiply,  and  enlarge,  and  acquire  many  nuclei 
which  fill  their  interior.  This  is  the  first  step.  In  the  second,  one  of  two 
things  may  take  place.  If  the  irritation  subsides  and  cell-production  is 
checked  btf  jre  the  nutrition  of  the  gland  is  interfered  with,  a  fatty  degen- 
eration takes  place  in  the  new  cells  which  reduces  them  to  a  milky  fluid. 
They  are  then  absorbed  and  the  gland  resumes  its  former  size.  If,  on  the 
contrary,  the  irritation  persist,  the  proliferation  of  cells  continues  ;  they 
crowd  together,  destroying  the  reticulum  and  the  capillar}'  network  of  the 
gland,  arrest  nutrition  by  their  pressure,  and  lead  to  rapid  disintegration 
and  suppuration.  This,  then,  is  an  active  process  conducted  rapidly.  In 
the  scrofulous  child  the  course  is  much  more  protracted.  The  glands  are 
apt  to  take  on  a  chronic  inflammatory  process.  They  increase  slowly  in 
size,  and  remain  a  long  time  as  indolent  lumps,  aj)parently  incajoable  of  fur- 
ther change  ;  or,  if  the  swelling  have  been  originally  acute,  no  diminution 
in  size  takes  place  when  the  inflammatory  process  is  at  an  end.  In  either 
case  the  gland  is  filled  with  proliferating  cells,  which  by  their  pressure 
hinder  nutrition,  and  induce  an  imperfect  fatty  degeneration,  so  that  the 
gland  is  converted  either  wholly  or  in  part  into  a  mass  of  cheesy  matter. 

Glands  so  affected  have  a  spongy  feel,  unless  there  is  much  hypertrophy 
of  the  connective  tissue,  in  which  case  they  become  hard.  Their  section 
is  pale  red,  passing  into  a  dirty  white  or  yellowish  colour.  After  a  time  the 
whole  gland  becomes  thick,  tough,  anaemic-looking,  and  dry,  and  is  then 
quickly  converted  into  an  opaque,  yellow,  caseous  mass.  Disease  in  the 
glands  is  unequally  distributed.  Some  are  unaltered,  and  even  of  those 
affected  there  is  great  variety  in  the  degree  to  which  the  jDrocess  extends, 
for  some  remain  small  while  others  enlarge  considerably.  After  remaining 
for  a  long  time  inactive  one  of  two  changes  may  take  place.  Either  the 
gland  softens,  sets  up  inflammation  around,  and  evacuates  its  contents  ; 
or  the  fluid  part  of  the  gland  is  absorbed,  and  the  gland  dwindles  into  a 
fibrous  mass,  or  is  hardened  by  the  deposition  of  earthy  salts.  The  cervi- 
cal glands  often  suppiu-ate  ;  the  bronchial  glands  occasionally  do  so,  but  in 
the  mesenteric  glands  such  a  termination  is  very  rare. 

Softening  and  suppuration  constitute  a  chief  danger  of  caseous  glands. 
In  the  glands  of  the  neck  this  is  of  less  moment  than  in  those  of  the  closed 
cavities,  for  their  contents  are  discharged  externally,  and  are  thus  removed 
from  the  body.  Even  in  these  cases  secondary  consequences  may  ensue. 
The  existence  of  a  chronic  discharging  sore,  such  as  often  results  from  the 
suppuration  of  these  glands,  is  very  apt  to  induce  amyloid  degeneration 
of  the  liver,  kidney,  and  spleen.  Therefore  these  organs  are  freqviently 
diseased  in  scrofulous  children.  Besides,  there  is  always  danger  that  soften- 
ing cheesy  matter  may  give  rise  to  an  explosion  of  acute  tuberculosis  ;  and 
many  scrofulous  children  fall  victims  to  this  fatal  disorder.  In  the  case  of 
the  bronchial  and  mesenteric  glands  softening  and  suppuration  are  still 
more  serious,  on  account  of  the  efi'ect  upon  neighbouring  organs.  This 
subject  will  be  referred  to  afterwards. 

Symj^ttoms. — In  a  well-marked  example  of  the  scrofulous  diathesis  the 
constitutional  tendency  often  expresses  itself  in  an  unmistakable  manner 
in  the  build  and  general  appearance  of  the  child.  He  is  stout  and  heavy, 
and  looks  as  a  rule  older  than  his  age.  The  subcutaneous  fat  is  usually 
over-developed,  and  in  places  remarkably  so.  His  face  is  broad  and  fat, 
with  a  thick  upi:)er  lip,  and  a  wide  nose.  The  limbs  are  stout,  with  thick 
ends  to  the  bones,  and  the  abdomen  is  inclined  to  be  large.  But  although 
the  adipose  tissue  is  relatively  increased,  there  is  a  want  of  firmness  about 
the  child's  flesh,  and  his  limbs  feel  soft  and  flabby.     Such  children  are  not 


176  DISEASE   IIX"   CHILDEEjST. 

necessarily  ill-favoured.  The  general  want  of  delicacy  and  refinement  in 
the  features  is  often  redeemed  by  the  large  size  and  dreamy  expression  of 
the  eye,  by  the  high  colour  in  the  cheeks,  and  by  the  redness  and  fulness 
of  the  lips. 

Such  characteristics  are,  however,  seen  only  in  pronounced  cases  of  the 
diathesis,  and  even  then  are  not  always  to  be  found.  All  the  tendencies  of 
the  scrofulous  constitution  may  be  active  in  a  child  without  his  presenting 
any  such  peculiarities  of  face  or  figure.  Indeed,  in  many  strumous  cases 
the  child  is  seen  to  have  a  spare  frame,  with  delicate  features  and  a  thin 
transparent  skin — a  type  which  conforms  more  to  the  tubercular  variety  of 
constitution  to  be  afterwards  desci'ibed.  But  whether  he  be  stout  and 
coarsely  built,  or  thin  and  delicately  framed,  there  is  one  indication  of  the 
diathetic  state  which  is  seldom  absent  in  a  strumous  subject.  This  is  the 
singular  activity  of  all  the  epithelial  structures.  The  hau'  is  soft,  thick,  and 
luxuriant;  the  eyelashes  and  eyebrows  are  well  marked  ;  and  in  many 
cases  there  is  a  remarkable  development  of  fine  down  covering  the  ears, 
cheeks,  shoulders,  and  spine.  The  skin,  moreover,  is  apt  to  be  rough 
and  scaly,  and  the  nails  grow  fast.  This  peculiarity  marks  one  of  the  es- 
sential features  of  the  scrofulous  diathesis,  viz.  :  a  tendency  to  rapid  pro- 
liferation of  all  the  epithelial  and  cellular  elements  of  the  body. 

It  has  been  said  that  the  scrofulous  diathesis  is  not  in  itself  a  disease. 
It  is  a  tendency  to  disease — a  tendency  to  derangements  of  structure  or  of 
function  which  finds  expression  under  suitable  conditions  in  a  variety  of 
lesions.  All  these  bear  a  common  character,  and  vary  in  gravity  according 
to  the  tissue  or  organ  affected.  The  lesions  are  infiammatory  in  their  na- 
ture, and  are  characterized  by  rapid  cell-growth  and  rapid  decay  of  the 
newly  formed  elements.  They  are  not  distinguished  by  any  special  ana- 
tomical characters  which  stamp  them  at  once  as  of  scrofulous  origin.  In 
appearance  they  do  not  differ  from  similar  derangements  occurring  in  chil- 
dren of  a  healthy  habit  of  body.  Their  constitutional  origin  is  shown  by 
their  tedious  course,  for  if  not  stopped  at  once  they  soon  pass  into  a  chronic 
state  ;  by  their  sluggish  response  to  treatment ;  and  by  their  proneness  to 
relapse  when  apparently  cured.  The  disturbance  originates  under  the  in- 
fluence of  some  trifling  and  temporarily'  exciting  cause  ;  and  the  length  of  its 
course  is  often  dependent  upon  the  hygienic  conditions  surrounduig  the 
child  at  the  time  of  the  attack.  If  these  are  satisfactory,  the  derangement 
may  be  quickly  recovered  from,  although  it  readily  recurs  when  a  similar 
cause  is  again  in  operation.  If  they  are  unsatisfactory,  as  is  usually  the 
case  amongst  the  poor,  the  derangement  becomes  a  chronic  disorder,  and 
increases  in  severity  and  obstinacy  as  the  days  go  by. 

The  parts  which  are  prone  to  suffer  in  this  diathesis  are  :  the  mucous 
membranes,  the  skin,  the  bones  and  joints,  the  organs  of  special  sense, 
and  above  all  the  lymphatic  glands.  In  whatever  tissue  the  lesion  is 
seated,  the  neighbouring  lymj^hatic  glands  are  liable  to  suffer ;  and  this  is 
a  fact  so  generally  recognized  that  amongst  the  public  the  term  "  scrofula" 
is  understood  to  mean  simply  a  chronic  enlargement,  with  tendency  to 
suppuration,  of  the  glands. 

The  mucous  membranes  in  all  strumous  children  are  especially  sensitive 
and  subject  to  catarrh.  Gastric  and  intestinal  catarrhs  are  very  common  ; 
and  we  find  besides,  coryza,  ophthalmia,  cataiThs  of  the  throat,  ear,  and 
au--passages,  and  in  guis  of  the  vulva.  All  these,  beginning  as  catarrhs, 
pass  quickly  into  chronic  inflammations  very  difficult  of  cure. 

The  affections  of  the  gastric  and  intestinal  mucous  membranes  will  be 
considered  in  another  place.     They  do  not  differ  from  the  same  derange- 


SCEOFULA — SYMPTOMS.  177 

ments  as  they  occur  in  healthy  subjects  except  in  the  fact — and  it  is  a  very 
important  one — that  in  scrofulous  children  such  catarrhs  are  always  accom- 
panied by  fever.  This  is  seldom  the  case  with  healthy  children.  If 
pyrexia  be  present  with  a  simple  gastric  catarrh,  it  affords  a  strong  pre- 
sumption that  the  patient  is  of  a  scrofulous  constitution.  Catarrhs  of  the 
intestine  in  these  children  often  set  up  ulceration  of  the  mucous  mem- 
brane. This  is  an  obstinate  lesion  and  may  lead  to  serious  consequences 
(see  Ulceration  of  the  Bowels). 

Catarrhs  of  the  nasal  passages  leading  to  ozsena,  and  even  destruction 
of  bone,  may  be  seen.  Obstinate  discharge  from  the  nose  in  a  baby  is 
generally  of  syphihtic  origin  ;  in  a  child  of  two  and  a  half  years  and  up- 
wards it  is  much  more  commonly  due  to  the  scrofulous  cachexia.  It  is 
very  obstinate,  gives  rise  to  a  distressing  and  perhaps  unavoidable  habit 
of  snuffling,  imparts  a  nasal  character  to  the  voice,  and  leads  to  cracking* 
and  excoriation  of  the  upper  lip. 

The  eyelids  and  eyes  may  be  affected  with  tinea  tarsi,  pustular  ophthal- 
mia, and  keratitis,  with  intense  lachrymation  and  photophobia. 

Pharyngeal  catarrh  is  a  very  common  affection.  It  is  also  a  very  im- 
portant one,  for  it  is  accompanied  by  some  enlargement  of  the  tonsils,  and 
considerable  swelling  and  thickening  of  the  posterior  nares  and  back  of 
the  fauces.  Consequently  there  is  occlusion  of  the  Eustachian  tubes  and 
deafness.  On  inspecting  the  back  of  the  fauces  in  such  cases  we  find  the 
mucous  membrane  of  a  deep  red  colour.  It  is  swollen  and  velvety,  and  is 
covered  with  a  thick  muco-pui'ulent  secretion.  The  closure  of  the  Eusta- 
chian tube  is  not  due  to  enlargement  of  the  tonsils,  but  to  the  swelling  of 
the  mucous  membrane.  Children  so  affected  present  a  peculiar  appear- 
ance. They  have  a  vacant  look,  hold  their  mouths  haK  open,  and,  hearing 
but  imperfectly  what  is  said  to  them,  hesitate  and  are  confused  when 
spoken  to.  They  ai-e  not  reaUy  wanting  in  intelligence,  but  on  account  of 
their  deafness  appear  to  be  so.  On  examination  of  the  ear  the  tympanum 
is  seen  to  be  drawn  in,  but  it  retains  its  translucency,  and  there  is  no 
tinnitus. 

Otorrhoea  is  very  often  met  with  in  scrofulous  children  from  catarrhal 
inflammation  of  the  meatus.  The  inflammation  may  spread  to  the  inner 
ear,  in  which  case  perforation  of  the  membrane  always  takes  place.  Severe 
primary  otitis  may  also  occur  as  a  result  of  cold  orinjui-y,  or  as  a  sequence 
of  scarlatina,  measles,  and  small-jDox. 

Pulmonary  catai'rhs  in  strumous  subjects  may  become  chronic  and  give 
rise  to  winter  cough,  with  emphysema  of  the  lungs  and  persistent  hyper- 
secretion ;  or  the  catarrh  may  spread  to  the  air-cells,  inducing  chronic 
catarrhal  pneumonia  with  all  its  possible  consequences. 

Various  skin  affections  occur  in  subjects  of  this  diathesis,  and  are  gen- 
erally the  earliest  manifestation  of  the  constitutional  tendency.  Acute 
eczemas  are  common,  and  slight  depressing  causes  may  give  rise  to  an^ 
outbreak  of  impetiginous  or  ecthymatous  pustules.  Little  scratches  are 
apt  to  run  into  festering  sores  which  may  be  slow  to  heal.  Occasionally 
we  find  rupia,  pemphigus,  or  lupus,  but  these  are  rare  in  childhood.  A 
not  uncommon  form  of  affection  of  the  skin  is  seen  in  babies  and  children 
under  two  years  of  age.  This  begins  as  a  small  lump — hard,  painless,  and 
of  the  size  of  a  pea  or  a  small  nut.  It  is  seated  in  the  subcutaneous  tissue,, 
and  the  skin  over  it  is  at  first  freely  movable  and  is  natural  in  colour- 
Gradually  an  adhesion  forms  between  the  little  mass  and  the  integument. 
The  skin  gets  red,  and  after  a  variable  time  gives  way,  and  the  cheesj 
contents  of  the  abscess  are  evacuated  wholly  or  in  part.  After  discharging 
12 


178  DISEASE   IIS"   CHILDEElSr. 

for  a  longer  or  shorter  period,  the  sore  heals  ;  its  hard  base  becomes  ab- 
sorbed ;  and  a  deep  cicatrix  is  left  at  the  site  of  the  abscess.  Several  of 
these  abscesses  are  usually  seen  at  the  same  time  in  various  stages  of  prog- 
ress. They  are  seated  on  the  arms,  legs,  or  abdominal  wall,  and  run  a 
protracted  course,  passing  very  slowly  through  their  several  stages.  They 
seldom  occur  except  in  childi'en  of  pronounced  stmmous  tendencies. 
"When  seated  on  parts  where  the  skin  is  in  close  contact  with  the  bone,  as 
on  the  fingers,  periostitis  may  be  set  up  with  exfoliation  of  bone  ;  but 
elsewhere  they  have  no  injurious  local  consequences. 

Disease  of  the  bones  and  joints  is  a  very  common  consequence  of  the 
scrofulous  diathesis.  These  affections  enter  more  particularly  into  the  de- 
partment of  the  surgeon.  StiU,  there  is  one  form  of  bone  disease  which  is 
brought  so  frequently  under  the  notice  of  the  physician  that  it  may  be 
properly  considered  in  connection  with  this  subject.  This  is  caries  of  the 
bodies  of  the  vertebrae,  in  its  early  stage,  before  it  has  led  to  curvatiu-e  of 
the  spine.  The  reason  why  we  so  often  see  such  cases  is  that  the  pain, 
which  is  one  of  the  earhest  symptoms  of  the  malady,  may,  by  its  seat  and 
by  the  cramp-like  character  it  sometimes  assumes,  give  little  indication  of 
its  being  generated  in  the  spine.  Like  the  pain  of  pleui'isy,  the  pain  of  ver- 
tebral caries  is  often  referred  to  a  region  far  distant  from  the  seat  of  the 
disease.  When  the  atlas  and  axis  are  affected,  the  pain  is  refeiTed  to  the 
occipital  region.  In  the  case  of  the  lower  cervical  vertebrae,  it  is  felt  in  the 
shoulders,  down  the  arms,  or  even  in  the  upper  part  of  the  breastbone. 
If  the  caries  occupy  the  dorsal  spine,  the  only  discomfort  complained  of 
may  be  in  the  sides  of  the  thorax,  the  middle  line  of  the  chest  in  front,  or 
the  epigastrium.  In  disease  of  the  lumbar  vertebrse  the  pain  is  reflected 
to  the  pelvis,  or  to  the  lower  limbs  as  far  as  the  knees,  or  even  to  the  feet. 
But  wherever  the  pain  is  felt,  and  whatever  may  be  its  degree  of  severity, 
its  cause  may  usually  be  distinguished  by  noting  the  increase  to  the  child's 
discomfort  when  he  moves  about,  and  the  relief  he  experiences  when  he 
lies  down.  Sometimes,  however,  slow  cautious  movement  may  be  made 
without  uneasiness ;  for  if  the  spine  be  braced  up  and  steadied  by  the  sui- 
rounding  muscles,  the  patient  may  be  able  to  move  carefully  about  with- 
out communicating  any  jar  to  the  vertebral  segments.  But  movement 
when  the  child  is  taken  at  a  disadvantage,  with  the  spinal  muscles  relaxed, 
is  always  distressing,  and  therefore  it  is  important  to  inquire  as  to  the 
effect  of  coughing,  sneezing,  riding  in  a  carriage,  or  making  a  false  step  in 
walking. 

Besides  pain,  another  important  indication  is  obtained  by  noticing  the 
degTee  of  mobility  retained  by  the  spinal  segments.  The  child  holds  his 
back  stiffly,  and  avoids  all  movements  which  necessitate  bending  of -the 
spine.  Thus,  when  laid  clown  on  his  back  and  told  to  get  up,  he  does  so 
by  turning  slowly  upon  his  hands  and  knees,  keej)ing  his  back  straight, 
and  then  getting  carefully  on  to  his  feet.  If  requii-ed  to  pick  up  a  small 
article  from  the  floor,  he  turns  sideways  to  the  object  and  lowers  and  raises 
liimseK  by  bending  and  straightening  his  knees,  keeping  the  spine  straight 
and  almost  erect.  Movements  such  as  these  are  of  great  value,  and  in 
doubtful  cases  the  child  should  be  put  through  a  series  of  exercises,  so  as 
to  test  thoroughly  the  mobihty  of  his  vertebral  column.  He  should  be  re- 
quu-ed  to  turn  round  quickly  as  he  walks,  to  climb  a  chau',  or  to  touch  his 
toes  with  outstretched  fingers  while  his  knees  are  straight. 

.  Another  important  symptom  is  the  attitude  assumed  by  the  patient 
when  at  rest.  If  there  '^be  much  disease  of  the  bones,  the  child  will  en- 
deavour to  rehevp  the  si^ine  by  supporting  his  head  or  diverting  the  weight 


SCROFULA — SYMPTOMS — CASEATION   OF   GLAl^DS.  179 

of  the  body  from  his  back  to  his  arms.  Thus  the  favourite  attitude  of  a 
child  whese  cervical  vertebrae  are  affected  is  to  sit  with  his  elbows  on  the 
table  supporting  his  head  with  his  hands.  In  other  cases  of  the  disease 
the  weight  of  the  body  is  transmitted  through  the  arms.  Mr.  Howard 
Marsh,  who  has  devoted  much  attention  to  this  subject,  describes  two  char- 
acteristic attitudes  assumed  by  a  child  the  subject  of  caries  of  the  dor- 
sal and  lumbar  spines.  In  one  of  these  he  places  the  palms  of  his  hands 
on  a  chair,  and  leans  over  forwards  with  his  arms  straight  and  shoulders 
raised.  By  this  means  Aveight  is  taken  off  the  spine  and  transmitted 
through  the  arms.  Another  position  is  equally  characteristic.  The  child 
rests  his  weight  on  one  toe,  with  the  heel  slightly  raised  and  the  knee 
flexed,  and  placing  his  hand  on  the  middle  of  the  thigh,  leans  over,  so  as 
to  convey  weight  from  the  shoulder  down  the  arm  to  the  limb. 

Attention  to  the  above  points  will  give  very  valuable  information. 
Other  symptoms  ai'e  less  trustworthy.  Thus  tenderness  on  pressure  over 
the  spines  of  the  diseased  vertebrj©  is  sometimes  present ;  but  it  is  not 
characteristic  of  caries.  Striking  with  the  knuckles  down  the  centre  of 
the  back  is  a  very  fallacious  test.  In  cases  of  undoubted  caries  there  may 
be  no  response  ;  and  a  child  may  shrink  when  the  spine  is  tapped  even 
though  the  bones  are  sound.  In  the  same  way  the  application  of  a  hot 
sponge  to  the  spine  as  a  test  of  tenderness  is  unsatisfactory,  and  in  the 
case  of  a  child  little  information  is  to  be  gained  by  this  means. 

Whenever  spinal  caries  is  suspected  we  should  never  forget  to  look  for 
iliac  or  psoas  abscess  ;  for  in  cases  where  the  ulceration  is  limited  to  the 
surface  of  the  bodies  of  the  vertebrae,  an  abscess  may  form  before  any 
curvature  can  be  detected  in  the  spine. 

Caseation  of  Glands. — One  of  the  most  familiar  consequences  of  the 
scrofulous  diathesis  is  a  chronic  enlargement  of  the  lymphatic  glands.  In 
all  young  subjects  these  glands  are  liable  to  enlarge  upon  slight  irritation  ; 
but  in  a  healthy  constitution  the  swelling  subsides  when  the  cause  which 
gave  I'ise  to  it  has  passed  away.  In  the  child  of  scrofulous  tendencies  the 
cause  exciting  the  morbid  process  may  be  so  feeble  and  transient  as  to 
escape  notice.  But,  the  unhealthy  action  once  set  up  runs  a  protracted 
course,  and  the  enlargement  continues  until  some  further  change  takes 
place  which  causes  it  to  disappear.  The  steps  by  which  the  affected  gland 
becomes  converted  into  a  cheesy  mass  have  already  been  described.  The 
process  is  a  purely  local  one,  and  does  not  necessarily  produce  any  ill 
effect  upon  the  patient.  It  is  evidence,  no  doubt,  of  a  constitutional  ten- 
dency, and  as  such  may  excite  apprehensions  of  other  and  more  formida- 
ble manifestations  of  the  diathetic  state.  Of  itself,  however,  unless  the 
swollen  glands  be  so  situated  as  to  press  injuriously  upon  parts  in  the 
neighbourhood,  or  to  threaten  by  setting  up  inflammation  around  to  injure 
a  vital  organ,  it  is  seldom  attended  with  danger. 

The  glands  most  commonly  affected  are  the  cervical,  the  bronchial,  and 
the  mesenteric. 

Chronic  enlargement  of  the  cervical  glands  is  excessively  common,  on 
account  of  the  many  scrofulous  lesions  to  which  the  head  and  face  are 
liable.  But  these  lesions  do  not  all  act  with  equal  energy  in  promoting 
the  glandular  swelling.  Inflammation  of  the  pharyngeal  mucous  mem- 
brane is  found  to  produce  this  result  far  more  frequently  and  readily  than 
an  irritant  occupying  any  other  part  of  the  head  and  face.  A  skin  affec- 
tion may  exist  for  a  long  time  without  causing  enlargement  of  the  glands, 
but  a  pharyngitis  causes  them  to  enlarge  very  quickly.  Chronic  glandular 
swellings  are  seen  as  round  or  oval  masses,  firm  to  the  touch,  and  usually 


180  DISEASE   m   CHILDREN. 

freely  movable.  The  skin  over  them  retains  its  normal  colour  and  is  not 
adherent.  They  are  generally  to  be  seen  behind  the  ear,  beneath  the 
lower  jaw,  and  sometimes  extending  down  the  neck  to  the  collar  bone. 
The  masses  may  be  formed  of  single  glands  ;  but  more  often  several  of 
these  unite  and  are  bound  together  by  thickened  and  condensed  cellular 
tissue.  Such  swellings  may  reach  the  size  of  a  small  apple.  Usually, 
after  a  time,  tenderness  begins  to  be  noticed  ;  the  skin  becomes  adherent 
and  red  ;  fluctuation  is  felt ;  and  eventually  the  abscess  bursts  and  dis- 
charges its  contents  externally.  Scrofulous  abscesses  are  slow  to  heal. 
Often  a  discharging  cavity  is  left  from  which  a  thin  pus  escapes ;  or  the 
opening  enlarges,  and  we  see  a  sluggish  ulcer  with  thickened  undermined 
edges.  In  bad  cases  several  of  these  may  be  seen  at  the  same  time  at  each 
side  of  the  neck. 

Enlarged  cervical  glands  do  not  always  suppurate.  Sometimes,  after 
remaining  a  variable  time  as  a  chain  of  indolent  swellings,  they  begin 
gradually  to  diminish  in  size  and  return  slowly  to  then*  normal  dimensions. 

Caseation  of  the  bronchial  glands  is  little  less  common  than  the  same 
condition  in  those  of  the  neck.  The  effect,  however,  of  such  disease  is 
very  different.  Swelling  of  the  superficial  glands  of  the  neck,  although 
unsightly  enough,  is  yet  in  itseK  a  complaint  of  comparatively  little 
moment.  But  when  the  glands  of  the  mediastinum  become  enlarged,  the 
consequences  may  be  serious.  The  glands  are  seated  at  the  bifurcation  of 
the  trachea,  behind  the  upper  bone  of  the  sternum,  and  a  little  below  it. 
They  also  accompany  the  bronchi  into  the  interior  of  the  lung.  When 
swollen,  the}^  must  therefore  encroach  upon  neighbouring  parts,  and  may 
jjroduce  considerable  disturbance  by  pressing  uipon  the  blood-vessels,  the 
air-passages,  and  the  nerves  of  the  chest. 

Before  describing  the  symptoms  j)roduced  by  this  means,  it  may  be 
remarked  that  enlargement  of  the  bronchial  glands  does  not  necessarily 
imply  the  existence  of  chronic  lung  disease.  A  child  is  not  to  be  con- 
sidered consumptive  because  his  mediastinal  glands  are  bigger  than  they 
ought  to  be.  The  term  "bronchial  phthisis,"  wdiich  has  been  applied  to 
this  condition,  is  very  misleading,  and  was  given  at  a  time  when  all 
chronic  changes  in  the  glands  were  attributed  to  tubercle.  Scrofulous 
children,  who  are  so  prone  to  suffer  from  pulmonary  catarrh,  will  generally 
be  found,  on  careful  examination,  to  have  some  swellings  of  the  glands  be- 
hind the  sternum  ;  but  if  no  dulness  or  bronchial  breathing  can  be  de- 
tected over  either  lung,  we  have  no  reason  to  infer  the  existence  of 
pulmonary  disease.  Like  the  same  affection  in  the  neck,  caseation  of  the 
glands  below  the  trachea  is  often  a  purely  local  process,  induced  in  a  scrof- 
ulous child  by  some  passing  irritation.  It  is  more  serious  than  a  similar 
condition  in  other  parts  only  because  the  glands  are  shut  up  in  a  closed 
cavity,  in  the  immediate  neighboui'hood  of  large  vessels  and  ^ital  organs, 
which  may  be  affected  injuriously  by  their  pressure,  or  by  pathological 
changes  occurring  in  them. 

It  is  possible  that  the  bronchial  glands  may  be,  as  most  authorities 
hold,  occasionally  the  seat  of  tubercle,  although  arguments  in  favour  of 
thi<?  view,  drawn  exclusively  from  morbid  anatomy,  are  of  only  secondary 
value.  But  there  is  little  doubt  that  the  ordinar}'  form  of  glandular  en- 
largement is  due  to  a  very  different  cause.  It  is  true  that  children  who 
suffer  from  this  form  of  scrofula  are  frecjuently  feverish,  and  that  they  are 
often  thin  and  under-nourished  ;  but  these  phenomena  are  not  necessarily 
the  result  of  tubercle.  It  wiU  be  generally  found  that  the  pyrexia  is  not 
a  constant  featiu'e  in  the  case.     It  occurs  now  and  again,  the  child's  tern- 


SCEOrULA — CASEATIOlSr   OF   GLANDS.  181 

perature  in  the  interval  being  normal,  and  lasts  on  each  occasion  for  a 
week  or  ten  days.  While  the  feverishness  continues,  the  child  is  languid 
and  mojJes,  eats  little  or  nothing,  and  is  generally  troubled  with  cough. 
The  explanation  is  that  a  child  suffering  from  this  cachexia  is  excessively 
sensitive  to  changes  of  temperature  and  readily  takes  cold.  While  the 
catarrh  lasts  he  is  feverish  ;  and  as  all  the  mucous  membranes  are  equally 
sensitive,  the  stomach  sympathizes  in  the  general  derangement.  For  the 
time,  then,  nutrition  is  in  abeyance,  and  he  loses  flesh.  Even  when  the 
attack  is  at  an  end,  and  appetite  returns,  the  stomach  does  not  all  at  once 
recover  its  power.  The  patient's  digestion  continues  weak  and  cannot 
fully  satisfy  the  requirements  of  his  system,  so  that  he  regains  flesh  but 
slowly.  If  the  catarrhs  recur  at  short  intervals,  the  child  is  kept  thin  and 
weak  ;  but  he  is  not  therefore  tubercular,  and  if  he  die,  he  dies  usually 
from  a  simple  bronchitis  or  pneumonia,  and  not  from  any  tubercular  com- 
plaint. But  such  children,  if  in  a  position  to  receive  all  the  care  they  re- 
quire, seldom  do  die.  In  my  experience  such  a  termination  is  rare  in  cases 
where  the  lungs  are  unaffected.  When  due  precautions  are  taken,  they 
often  become  fat  and  strong,  and  the  signs  of  glandular  enlargement  dis- 
appear. 

In  many  cases  the  disease  in  the  glands  is  associated  with  pulmonary 
phthisis ;  but  this  is  more  often  than  not  of  the  non-tubercular  variety. 
When  death  takes  place  in  such  cases  it  results  from  the  lung  disease,  and 
the  glandular  swelling  contributes  little,  if  at  all,  to  the  fatal  issue.  Death, 
however,  does  sometimes  occur  as  a  consequence  of  the  scrofulous  swell- 
ing. The  mass  may  cause  such  disturbance  by  jDressure  upon  neighbour- 
ing parts  that  inflammation  and  ulceration  are  set  up,  and  the  child  sinks 
from  exhaustion.  Thus  the  oesophagus  or  an  air-tube  may  be  perforated, 
as  in  a  case  published  by  Dr.  Gee,  without  any  softening  having  occurred 
in  the  gland.  In  other  cases  the  gland  softens  and  becomes  converted  into 
a  mass  of  pus.  Here  there  is  hectic  fever,  general  and  persistent  wast- 
ing, and  loss  of  strength.  Eventually  the  abscess  discharges  itself  into  the 
pleural  cavity,  into  a  bronchus,  or  into  a  large  vessel,  causing  fatal  haemor- 
rhage. A  common  termination  when  softening  takes  place  in  the  gland  is 
by  acute  tuberculosis.  This,  however,  may  occur  in  the  case  of  any  other 
softening  cheesy  mass  wherever  situated.  It  is  no  proof  that  the  gland 
was  originally  the  seat  of  tubercle. 

The  special  symptoms  produced  by  enlargement  of  the  mediastinal 
glands  are  the  consequence  of  pressure — the  glands  by  their  unwonted  size 
encroaching  upon  the  parts  around. 

Pressure  upon  the  superior  vena  cava,  or  either  innominate  vein,  inter- 
feres with  the  return  of  blood  to  the  heart.  There  is  a  certain  degree  of 
lividity  of  the  face,  the  skin  around  the  mouth  has  a  bluish  tint,  and  the 
lips  look  puffy  and  dark.  The  suj)erficial  veins  also  are  unusually  visible 
in  the  temples,  the  neck,  and  over  the  front  of  the  chest  and  shoulders.  A 
small  amount  of  pressure  is  sufficient  in  children  to  cause  dilatation  of  the 
"venous  radicles  of  the  chest,  and  the  symptom  is  one  of  the  earliest  indi- 
cations that  the  bronchial  glands  are  larger  than  they  ought  to  be.  If 
there  be  great  obstruction  to  the  return  of  blood  from  the  head,  oedema 
of  the  face  and  puffiness  of  the  eyelids  may  be  seen ;  and  this,  when  one 
innominate  vein  only  is  pressed  upon,  is  limited  to  one  side  of  the  face. 
On  account  of  the  congestion  of  the  venous  sjstem,  epistaxis  is  common, 
and  haemorrhage  may  even  occur  from  the  lungs.  But  haemoptysis  in  chil- 
dren is  difi&cult  to  detect,  for  blood  coming  up  from  the  air-tubes  is  al- 
most invariably  swallowed,  while  a  discharge  of  blood  from  the  mouth  is 


182  DISEASE  IN   CHILDEEl^. 

usually  the  consequence  of  epistaxis,  the  blood  escaping  backwards  into 
the  throat  from  the  posterior  cares. 

Pressure  on  the  nerves  of  the  chest  causes  hoarseness  of  the  voice  and 
paroxysmal  cough  which  may  be  mistaken  for  whooping-cough.  It  occiu's 
in  violent  fits,  and  sometimes  ends  in  a  crowing  inspii-ation.  It  is,  how- 
ever, seldom  followed  by  vomiting.  When  the  pressure  affects  also  the 
lower  end  of  the  trachea  at  its  bifurcation  there  maybe,  in  addition,  attacks 
of  dyspno9a.  These  are  the  ordinary  "  asthmatic  attacks  "  of  young  children. 
Sometimes  larjoigeal  spasm  is  induced,  and  long-continued  spasm  may  so 
interfere  with  the  entrance  of  air  into  the  lungs  that  the  antero-posteiior 
diameter  of  the  chest  becomes  diminished,  the  weight  of  the  atmosphere 
forcing  the  sternum  backwards  below  the  level  of  the  ribs.  All  these  press- 
ure symptoms  become  greatly  aggravated  by  an  attack  of  pulmonary  ca- 
tarrh. In  ordinary  cases  severe  symptoms  are  only  seen  when  the  child 
catches  cold.  If  this  happen,  the  condition  of  the  patient  becomes  alarm- 
ing. His  face  is  livid  ;  his  dyspnoea  distressing  ;  his  voice  hoarse  ;  his 
cough  violent  and  spasmodic.  Even  then  the  attack  is  often  not  continu- 
ous. It  occurs  in  sudden  seizures  which  come  on  once,  or  more  often,  in 
the  day,  or  only  at  night.  The  attacks  last  a  variable  time  and  create 
much  alarm.  In  most  instances  their  violence  abates  after  a  few  days, 
and  in  the  course  of  a  week  or  so  the  child  seems  restored  to  his  ordinary 
health,  although  he  is  left  languid  and  more  feeble  than  before  his  illness. 
In  other  cases  the  symptoms  increase  in  severity  instead  of  diminishing. 
The  child  stai'ts  up  suddenly  in  his  bed  with  staring  eyes  and  a  dusky, 
frightened  face  ;  his  respu-atory  muscles  work  violently,  and  his  agitation 
and  distress  are  painful  to  see.  After  several  repetitions  of  these  attacks 
death  may  take  place  either  suddenly,  or  after  a  fit  of  convulsions. 

The  physical  signs  afforded  by  examination  of  the  chest  are  of  impor- 
tance. In  marked  cases  we  find  dulness  on  the  first  bone  of  the  sternum, 
which  may  extend  for  some  distance  on  each  side  and  below.  Sometimes 
it  is  found  to  reach  as  far  downwards  as  the  base  of  the  heart.  I  have 
never  succeeded  in  detecting  any  dulness  in  the  back  between  the  scapulae. 
Indeed,  the  results  of  percussion  even  in  front  are  often  misleading.  There 
may  be  very  considerable  and  extensive  disease  in  the  glands,  and  unless 
the  mass  is  in  actual  contact  with  the  wall  of  the  chest  no  dulness  may  be 
discovered  at  the  spot.  The  signs  afforded  by  the  stethoscope  are  much 
more  trustworthy'.  Pressure  upon  the  lower  part  of  the  trachea  produces 
a  respiratory  stridor  which  is  sometimes  so  loud  as  to  be  heard  at  a  distance 
from  the  chest.  It  is  generally  intermittent.  In  either  bronchus  marked 
pressure  may  interfere  with  the  entrance  of  air  into  the  corresponding  lung, 
and  lead  to  a  certain  amount  of  collapse  at  the  base.  Pressure  such  as  ^his, 
however,  is  exceptional,  and  is  only  seen  in  cases  where  the  enlargement  is 
great.  The  most  common  auscultatory  sign  connected  with  the  breathing 
is  produced  by  conduction,  the  glands  forming  an  artificial  medium  of 
communication  by  which  sound  is  conveyed  from  the  air-tubes  to  the  chest 
wall.  This  gives  to  the  breathing  a  loud  blowing  character  which  is  very 
characteristic.  It  is  less  high  pitched  and  metallic  than  the  ordinary  blow- 
ing and  cavernous  breathing  heard  in  cases  of  pulmonary  consolidation  and 
excavation  ;  and  is  most  marked  at  the  apices  of  the  lung,  especially  at  the 
supra-spinous  fossEe.  Sometimes  it  is  heard  loudly  over  the  whole  of  one 
or  both  sides  of  the  chest.  Opening  the  mouth  generally  modifies  consid- 
erably the  intensity  of  this  blowing  quahty,  and  may  even  make  it  cease 
altogether. 

Pressure  upon  the  descending  vena  cava  or  the  left  innominate  vein 


SCROFULA — SYMPTOMS — CASEATIOIST   OF   GLANDS.  183 

gives  rise  to  a  hum,  and  on  the  pulmonary  artery  to  a  systoHc  murmur 
heard  best  at  the  second  left  interspace.  But  long  before  the  ordinary 
signs  of  pressure  on  the  vessels  can  be  detected,  we  can  induce  pressure 
on  the  vein  if  the  bronchial  glands  are  enlarged.  This  sign  is  one  of  the 
earliest  indications  of  disease  in  these  glands.'  Thus,  if  the  child  be  di- 
rected to  bend  his  head  backwards  upon  his  shoulders  so  that  his  face  is 
■  turned  upwards  to  the  ceiling  above  him,  a  venous  hum,  which  varies  in 
intensity  according  to  the  size  and  position  of  the  swollen  glands,  may  be 
heard  with  the  stethoscoj^e  placed  upon  the  upper  bone  of  the  sternum. 
As  the  chin  is  slowly  depressed  again  the  hum  becomes  less  distinctly  audi- 
ble, and  ceases  shortly  before  the  head  reaches  its  ordinary  position.  The 
explanation  of  this  phenomenon  appears  to  be  that  the  retraction  of  the 
head  tilts  forward  the  lower  end  of  the  trachea.  This  carries  with  it  the 
glands  lying  in  its  bifurcation,  and  the  left  innominate  vein  is  compressed 
where  it  passes  behind  the  first  bone  of  the  sternum.  I  believe  this  ex- 
planation to  be  the  correct  one,  for  in  cases  of  merely  flat  chest,  where  there 
is  no  reason  to  suspect  enlargement  of  the  glands,"  the  experiment  fails. 
Nor,  again,  can  the  hum  be  produced  in  a  healthy  child  by  the  thymus 
gland.  This  gland  lies  in  front  of  the  vein  immediately  behind  the  sternum. 
Enlarged  bronchial  glands  lie  behind  the  vessels  in  the  bifurcation  of  the 
trachea.  A  swelling  in  front  of  the  vessels  does  not  appear  to  be  able  to 
set  up  pressure  upon  the  vein  when  the  head  is  bent  backwards  in  the 
position  described.  Again,  in  order  that  the  experiment  should  succeed, 
the  lower  end  of  the  trachea  must  not  be  fixed,  and  the  glands  lying  below 
its  bifurcation  must  be  movable,  otherwise  no  hum  is  heard  when  the  head 
is  retracted.  Thus  a  child  was  admitted  into  the  East  London  Children's 
Hospital  for  lymphadenoma.  There  was  dulness  at  the  upper  part  of  the 
sternum,  and  downwards  as  far  as  the  base  of  the  heart.  In  this  case,  to 
my  great  surprise,  no  venous  hum  could  be  heard.  The  child  died,  and 
on  examination  of  the  body,  yellow,  flattened,  cheesy  masses  were  found 
adherent  to  the  inner  side  of  the  sternum,  and  others,  Yerj  large  and  im- 
movable, were  seen  filhng  up  the  interval  between  the  bifurcations  of  the 
trachea.  The  lower  end  of  the  air-tube  was  held  firmly  down  by  the  mass, 
consequently  pressure  could  not  be  brought  to  bear  upon  the  vein  by  bend- 
ing of  the  head,  as  the  glands,  being  fixed,  could  not  be  brought  forwards 
against  the  vessel.  The  experiment  may  sometimes  fail  even  in  cases  where 
the  lower  end  of  the  trachea  with  its  caseous  glands  is  free  to  move,  for  the 
relative  position  of  the  glands  and  the  vein  may  not  correspond  ;  but  as  a 
rule  it  will  succeed,  and  a  venous  hum,  so  induced,  is,  I  believe,  a  certain 
sign  that  the  glands  of  the  mediastinum  are  not  healthy. 

The  mesenteric  glands  are,  perhaps,  less  commonly  afiected  than  those 
of  the  neck  or  the  chest ;  but  disease  in  them  is  far  from  rare,  although  it 
cannot  always  be  detected  during-  life.  The  affected  glands  may  be  sepa- 
rate, or  they  may  unite  as  in  other  situations  into  masses  bound  together 
by  thickened  cellular  tissue.  In  this  way  a  mass  the  size  of  an  apple,  and 
more  or  less  movable  may  be  felt  on  manipulation  of  the  abdomen. 

The  old  name  for  disease  of  the  mesenteric  glands  was  tabes  mesen- 
terica,  and  very  serious  consequences  were  described  as  i^esulting  from  the 
glandular  enlargement.  It  is  now  known  that  these  symptoms  are  due, 
not  to  the  mesenteric  swellings,  but  to  the  lesion  of  which  they  are  the  con- 
sequence ;  and  that  the  caseous  glands  form  a  part — and  often  only  a  very 

'  See  a  paper  "by  the  writer,  "  On  the  Early  Diagnosis  of  Enlarged  Bronchial  Glands." 
Lancet,  August  14,  1875. 


184  DISEASE  IN   CHILDEEN. 

insignificant  part — of  the  disease  from  whicli  the  patient  is  suffering.  Like 
the  lymphatic  glands  in  other  situations,  those  of  the  mesentery  swell  up 
as  a  result  of  irritation  or  inflammation  in  the  parts  from  which  the  lym- 
phatic vessels  passing  through  them  take  their  origin.  In  strumous  sub- 
jects they  have  the  same  proneness  as  the  others  to  become  caseous.  Of 
themselves  they  form  a  strong  argument  against  the  tubercular  theory  of 
scrofulous  glandular  enlargement ;  for  caseation  of  the  mesenteric  glands,  • 
unless  their  size  be  such  that  they  press  upon  neighbouring  parts,  is  in 
itself  a  by  no  means  serious  matter.  In  ordinary  cases,  where  there  is 
no  accompanying  lesion  of  the  bowels,  the  child's  nutrition  is  good  ;  his 
spirits  and  appetite  are  satisfactory  ;  his  temperature  is  normal ;  and  ex- 
cept, perhaps,  for  some  slight  pallor  of  face,  he  may  show  no  sign  of  ill- 
health.  In  most  cases,  however,  swelling  of  the  glands,  if  at  aU  considera- 
ble, is  combined  with  scrofulous  ulceration  of  the  bowels  ;  but  even  here 
the  consequences  are  not  always  as  serious  as  might  be  expected.  Much 
depends  upon  whether  or  not  the  ulceration  of  the  intestine  is  accompanied 
by  a  catarrhal  condition  of  the  mucous  membrane.  If  this  be  present, 
there  is  diarrhoea  with  marked  disturbance  of  nutrition.  The  child  grows 
thinner,  paler,  and  weaker ;  his  expression  is  distressed ;  he  sleeps  badly  at 
night,  often  asking  for  drink,  and  is  disturbed  by  wandering  abdominal 
pains.  The  temperature  may  rise  slightly  in  the  evening,  but  there  is 
seldom  marked  pyrexia. 

If  there  be  no  intestinal  catarrh,  the  bowels  may  be  confined,  and  the 
effect  upon  the  child's  general  health  is  much  less  pronounced.  He  still 
looks  ill,  is  troubled  by  flatulent  pains,  and  is  pale  and  weakly  ;  but  nu- 
trition may  be  fairly  performed,  and  the  child  may  even  appear  stout, 
although  to  the  touch  his  limbs  feel  soft  and  flabby  (see  IJlceration  of 
Bowels) . 

When  caseation  of  the  glands  is  associated  with  tubercular  peritonitis 
— and  it  is  to  this  combination  that  all  old  descriptions  of  tabes  mesenterica 
apply — the  symptoms  are  those  of  the  peritoneal  disease,  and  the  case  is  a 
very  serious  one. 

Scrofulous  mesenteric  glands  are  not  always  easy  to  detect.  The  belly 
is  so  often  distended  in  children,  with  flatulent  accumulations,  that  it  may 
be  difficult  to  force  the  parietes  sufficiently  inwards  to  reach  the  swollen 
bodies.  Moreover,  a  certain  tension  of  the  abdominal  wall,  more  or  less 
voluntary,  may  still  further  increase  the  difficulty.  The  enlarged  glands 
lie  about  the  middle  of  the  abdomen,  in  front  of  the  spine.  If  the  mass  be 
a  large  one,  ^Dressing  the  abdominal  wall  directly  inwards  will  usually  de- 
tect the  swelling  at  once.  In  cases  where  the  increase  in  size  of  the  glands 
is  inconsiderable,  it  is  better  to  make  pressure  laterally,  bringing  the  hands 
together  from  the  sides  towards  the  centre,  so  as  to  catch  the  little  mass 
between  the  fingers. 

If  the  glands  are  large  enough  to  press  upon  the  parts  around,  there 
may  be  oedema  of  the  legs  and  scrotum  from  pressure  ujDon  the  vena  cava. 
This,  however,  is  exceptional.  A  very  small  amount  of  pressure  will  be 
sufficient  to  cause  dilatation  of  the  superficial  veins  of  the  abdominal  wall ; 
and  most  cases  of  enlarged  mesenteric  glands  are  accompanied  by  this 
phenomenon.  Cramps  in  the  legs  are  said  to  be  sometimes  caused  by 
pressure  upon  the  nerves  of  the  abdomen  ;  and  ascites  may  be  the  conse- 
quence of  pressure  upon  the  portal  vein  by  the  glands  occupying  the 
hepatic  notch. 

The  usual  terniination  of  scrofulous  glands  in  the  abdomen  is  that  by 
shrinking  and  petrifaction.     They  rarely  soften,  although  cases  are  re- 


SCEOFIJLA — SYMPTOMS— DIAGj^OSIS.  185 

corded  in  wLich  suppurating  glands  have  become  adherent  to  a  coil  of 
intestine  and  have  discharged  their  contents  into  the  bowel. 

From  the  preceding  description  it  will  be  seen  that  the  phenomena 
produced  by  the  development  of  the  scrofulous  cachexia  are  very  numer- 
ous. The  manifestations  of  the  diathesis  must  therefore  vary  greatly  in 
different  cases,  the  constitutional  tendency  exjDressing  itseK  now  in  one 
way,  now  in  another  ;  for  in  addition  to  the  general  predisposition,  the  child, 
seems  also  to  inherit  a  special  weakness  of  particular  tissues.  Thus,  in  one 
family  we  see  child  after  child  suffer  from  scrofulous  inflammation  of  the 
eye ;  in  another  there  is  equal  susceptibility  of  the  pharyngeal  or  the  nasal 
mucous  membranes  ;  in  a  third  we  detect  a  special  proneness  to  disease  of 
the  bones  or  of  the  joints.  All  these  disorders  are  apt  to  run  a  tedious 
course  and  to  resist  treatment  with  singular  obstinacy.  They  can  only  be 
attacked  successfully  by  using  means  which  improve  nutrition,  and  weaken 
the  morbid  tendency  on  which  the  lesion  depends.  Until  this  be  done 
mere  local  applications  will  be  of  small  value. 

Diagnosis. — It  has  been  said  that  scrofulous  lesions  have  no  special 
characters  which  indicate  their  constitutional  origin.  Their  real  nature 
must  therefore  be  inferred  from  their  lingering  course,  their  tendency 
to  x'ecur,  the  frequent  absence  of  any  discoverable  local  cause  to  account 
for  them,  and  the  coexistence  of  other  disorders  of  a  like  nature,  espe- 
cially of  glandular  enlai-gements. 

The  subcutaneous  abscesses  may  be,  and  often  are,  mistaken  for  syph- 
ilitic gummata.  They  must  be  distinguished  by  the  history  of  the  case, 
noting  the  complete  absence  from  it  of  any  syphilitic  symptoms. 

The  diagnosis  of  the  early  stage  of  spinal  caries  has  been  already  indi- 
cated in  the  description  of  that  disease.  Remembering  how  the  pain  radi- 
ates in  this  affection  to  distant  parts,  we  should  always  look  with  suspicion 
upon  pain  in  the  chest  or  stomach  in  a  child  of  scrofulous  tendencies  until 
the  spine  has  been  tested  for  the  effect  of  sudden  jars  or  shocks,  and  the 
child's  attitudes  as  he  walks  or  plays  have  been  inquired  into.  Persistent 
pain  in  the  occipital  region,  if  combined  with  any  stiffness  in  the  neck  or 
any  altered  manner  of  holding  the  head,  is  always  suspicious  of  caries  of 
the  cervical  vertebrae.  Pain  in  the  chest  or  stomach,  unaffected  by  food 
but  increased  by  movement  and  relieved  by  lying  down,  is  highly  sugges- 
tive of  dorsal  caries.  In  all  cases  where  spinal  disease  is  suspected  the 
child  should  be  made  to  raise  himself  from  a  recumbent  position,  to  pick 
up  a  small  object  from  the  floor,  or  to  climb  on  to  a  chair  or  table,  and 
his  manner  of  performing  these  acts  should  be  carefully  observed,  noting 
the  degree  of  movability  of  the  spine,  and  whether  any  part  of  it  is  held 
rigid. 

In  the  case  of  enlarged  glands  we  may  consider  that  a  gland  has  be- 
come cheesy  if  it  have  enlarged  without  evident  cause,  and  if  it  persist  for 
a  long  time  as  a  painless  indolent  tumour  showing  no  tendency  to  subside. 

Caseation  of  the  bronchial  glands  may  be  detected  in  their  early  stage 
by  the  experiment  of  listening  over  the  upper  bone  of  the  sternum  while 
the  child's  head  is  retracted,  as  already  described.  Dulness  at  the  upper 
part  of  the  sternum,  if  combined  with  any  sign  of  pressure,  is  very  sus- 
picious, especially  if  there  be  fulness  of  the  superficial  veins  of  the  neck, 
side  of  the  head,  and  temples.  Spasmodic  breathing  and  paroxysmal  cough 
are  also  characteristic  symptoms — the  more  so  if  they  are  combined  with 
any  altered  quahty  of  voice.  In  aU  cases  where  children  have  attacks  of  so- 
called  "  asthma,"  attention  should  be  always  directed  to  the  bronchial 
glands  (see  page  182). 


186  DISEASE   IlSr   CHILDEEN. 

In  the  case  of  the  mesenteric  glands  the  only  satisfactory  proof  of  their 
enlargement  is  holding  them  between  the  fingers.  Even  in  these  cases, 
however,  we  have  to  satisfy  ourselves  that  the  substance  is  really  a  gland, 
and  not  a  cheesy  mass  attached  to  the  omentum,  or  a  lump  of  hardened 
fasces.  Cheesy  omental  masses  are  much  more  superficial,  and  consequently 
more  easily  felt  than  enlarged  glands.  They  are  also  more  freely  mova- 
ble. In  feeling  for  mesenteric  glands  the  fingers  have  to  be  pressed 
down  firmly  towards  the  spine,  and  the  glands,  if  enlarged,  can  be  detected 
as  slightly  movable  lumps  with  ill-defined  margin. 

The  sensation  conveyed  to  the  fingers  by  feecal  masses  is  very  different 
to  that  furnished  by  enlarged  glands.  Faecal  accumulations  can  be  readily 
studied  in  cases  of  tyj)hoid  fever  where  there  is  no  diarrhoea,  and  the  cliild 
is  taking  milk.  Here  we  find  elongated  masses  of  moderate  size  lying 
with  their  long  axes  in  the  direction  of  the  bowel,  and  situated  at  some 
point  in  the  course  of  the  colon.  They  are  never  very  deeply  placed,  and 
can  be  always  readily  reached  by  shght  depression  of  the  abdominal  wall. 
By  firm  pressure  they  can  be  indented  by  the  finger.  If  any  doubt  is  felt 
in  such  a  case,  the  effect  of  a  copious  enema  should  be  tried.  Fsecal  masses 
are  readily  removed  by  this  means ;  while  lumps  due  to  any  other  cause 
are  only  made  more  evident  by  the  injection  ;  for  this  b}^  removuig  gaseous 
distention  and  fsecal  matters,  renders  a  full  exploration  of  the  abdominal 
cavity  more  easy  than  before. 

Prognosis. — It  is  the  exception  for  scrofulous  children  to  die  from  the 
direct  effects  of  the  disease.  In  fatal  cases  death  usually  results  from 
acute  tuberculosis  ;  the  outbreak  of  the  tubercular  malady  being  deter- 
mined by  some  mysterious  process  of  infection  through  softening  cheesy 
matter  or  slowly  ulcerating  bone.  Again,  children  the  subjects  of  this 
diathesis  are  more  sensitive  to  the  ordinary  causes  of  disease.  They  catch 
cold  very  readily,  and  therefore  are  apt  to  suffer  from  various  chest  affec- 
tions. These,  besides  their  own  special  dangers,  may  lead  to  evil  conse- 
quences by  causing  enlargement  and  caseation  of  the  bronchial  glands. 
Pneumonia,  again,  has  a  risk  of  its  own  in  its  proj)ensity  to  undergo  only 
partial  absorption,  and  so  to  induce  chronic  changes  in  the  lung. 

Scrofulous  children  are  singnilarly  susceptible  to  the  influence  of  conta- 
gion. Few  such  children  exjDOsed  to  the  infective  principle  of  zymotic  dis- 
ease will  be  found  to  escape,  unless  protected  by  a  previous  attack.  Such 
diseases,  too,  have  a  special  power  of  intensifjdng  the  diathetic  taint.  They 
leave  the  child  not  only  depressed  by  his  late  illness,  but  also  more  exposed 
than  before  to  suffer  from  the  consequences  of  his  constitutional  weakness. 

Enlarged  bronchial  glands,  if  sufficiently  advanced  to  cause  serious  pres- 
sure upon  parts  around,  must  always  occasion  anxiety.  If  there  be  lividity 
of  face  or  attacks  of  dyspnoea,  a  very  guarded  prognosis  should  be  given. 
StiU,  when  placed  under  favourable  conditions  such  children  often  do  well. 

Enlarged  mesenteric  glands,  if  unaccompanied  by  ulceration  of  bowels 
or  signs  of  tubercular  peritonitis,  are  in  themselves  of  little  importance. 
If  signs  of  intestinal  ulceration  be  present,  the  case  is  more  serious,  and 
the  prognosis  depends  upon  the  amount  of  diarrhoea,  the  presence  of  dis- 
ease in  other  organs,  and  the  effect  of  the  lesion  upon  the  nutrition  of  the 
patient.     This  subject  is  considered  in  another  place  (see  page  665). 

Amyloid  disease  of  organs  set  up  by  chronic  suppuration  is  of  moment, 
as  tending  to  induce  anaamia  and  lower  the  strength.  Still,  in  childhood, 
if  the  primary  suppuration  be  arrested  and  the  scrofulous  disease  removed, 
the  amyloid  degeneration  often  undergoes  a  surprising  improvement  (see 
"  Amyloid  Liver  "). 


SCEOFULA — TEEATMENT.  187 

Treatment. — The  constitutional  tendency  to  scrofulous  lesions  is  best 
attacked  by  measures  which  encourage  and  maintain  healthy  nutrition. 
The  causes  which  excite  the  dormant  cachexia  have  been  stated  to  be  ex- 
posure to  cold  and  damp,  insufficient  and  unsuitable  food,  impure  air,  and 
want  of  exercise.  It  is  therefore  evident  that  a  careful  regulation  of  the 
diet,  combined  with  warm  .clothing  and  daily  exercise  in  the  open  air,  must 
be  the  first  measures  to  be  adopted. 

With  regard  to  food,  the  child  should  be  fed  liberally  ;  meat,  fresh 
eggs,  and  milk  should  enter  largely  into  his  diet,  and  his  stomach  should 
not  be  overloaded  with  puddings  and  starchy  matters  to  the  exclusion  of 
more  strictly  nourishing  articles  of  food.  Fresh  vegetables  are  a  valuable 
addition  to  his  dietary,  but  potatos  must  be  given  with  caution,  although 
they  are  not  to  be  entirely  excluded.  If  the  appetite  be  poor,  a  small 
amovmt  of  stimulant  is  often  of  service,  and  the  child  should  be  allowed  a 
good  winegiassful  of  sound  claret  diluted  with  an  equal  quantity  of 
water  to  his  dinner.  It  is  needless  to  say  that  cakes  and  sweetmeats  be- 
tween meals  must  be  strictly  forbidden.  In  the  case  of  infants  born  of 
scrofulous  parents,  a  healthy  wet-nurse  should  be  provided  if  the  mother 
be  unable  to  suckle  her  child.  If  this  be  impossible,  the  utmost  vigilance 
must  be  exercised  in  the  feeding  and  general  management  of  the  baby. 
Directions  are  given  elsewhere  for  the  healthy  rearing  of  infants,  and  the 
reader  is  referred  to  the  chajDter  on  "  Infantile  Atrophy  "  for  fuller  informa- 
tion upon  this  important  subject. 

Climate  is  a  matter  of  great  moment  for  children  who  are,  or  are  likely 
to  be,  the  subjects  of  scrofula.  A  bracing  air  is  indispensable  to  the  suc- 
cessful treatment  of  these  cases.  Residence  in  low-lying  clay  soils  does 
much  to  encourage  the  predisposition,  while  sandy  or  gravelly  places,  with 
a  dry  air,  are  of  the  greatest  benefit  in  increasing  the  vigour  of  the  consti- 
tution. On  account  of  the  tendency  to  catarrhs  in  this  diathesis,  a  dry  air 
is  of  especial  importance  ;  and  a  place  which  is  sufficiently  warm  during 
the  winter  months  to  allow  of  the  patient  passing  a  lai'ge  part  of  his  time 
out  of  doors  is  of  the  utmost  service.  Large  towns,  with  their  smoke  and 
vitiated  aii*,  are  bad  residences  for  scrofulous  children.  When  compelled 
to  live  in  cities,  care  should  be  taken  that  the  child  is  warmly  clothed  and 
sent  out  as  much  as  possible  for  exercise  in  the  large  open  spaces  with 
which  most  towns  are  now  provided.  For  children  of  both  sexes  healthy 
out-of-door  games  should  be  encouraged  ;  and  they  should  be  early  trained 
in  suitable  gymnastic  exercises,  such  as  develop  the  muscles  and  expand 
the  chest. 

The  skin  should  be  kept  perfectly  clean  by  a  daily  bath,  but  cold 
douches  are  often  too  depressing  for  such  subjects,  unless  employed  ac- 
cording to  the  plan  recommended  for  delicate  children  (see  Introduction). 
The  bowels  must  be  attended  to,  and  habits  should  be  inculcated  of  regu- 
larity in  the  use  of  the  close-stool.  When  aperients  are  required  drastic 
purgatives  should  be  avoided.  It  is  better  to  employ  mildly  acting  drugs, 
such  as  the  compound  liquorice  powder,  or  to  combine  an  aperient  with  a 
tonic,  as  in  giving  the  infusion  of  senna  with  the  infusion  of  gentian  or 
orange-peel. 

In  treating  children  in  whom  the  cachexia  hfis  become  developed,  the 
above  matters  must  be  carefully  attended  to.  Gri'eat  stress  should  be  laid 
upon  the  value  of  a  suitable  climate  in  aiding  the  child's  recovery  of  health. 
If  possible,  the  patient  should  be  sent  to  winter  in  a  dry  air  sheltered  from 
cold  winds.  There,  dressed  from  head  to  foot  in  warm,  woollen  clothing, 
he  should  spend  the  greater  part  of  his  time  out  of  doors.     Cod-liver  oil  is 


188  DISEASE  IlSr   CIIILDEEN'. 

usually  prescribed,  indiscriminately  in  these  cases,  and  "wliile  some  children 
appear  to  be  gi-eatly  benefited  by  the  prescription,  others  seem  almost  in- 
sensible to  its  effects.  It  may  be  laid  doT\TL  as  a  rule  that  the  stout  scrofu- 
lous children  are  not  the  best  subjects  for  cod-liver  oil.  It  is  the  spare 
framed  child  with  an  active,  nervous  system  who  derives  most  benefit  from 
the  use  of  the  drug.  The  oil  should  be  given  in  doses  of  one  teasj)oonful 
two  or  thi-ee  times  a  day,  and  its  use  must  be  continued  for  months  to- 
gether. If  the  child  apjDear  to  be  nauseated  by  this  constant  dosing,  the 
oil  may  be  remitted  for  a  few  days  at  a  time,  but  must  be  shortly  resumed. 
On  the  Continent  much  value  is  attached  to  acorn  cofiee,  made  by  roasting 
together  a  mixture  of  acoms  and  coffee  beans  and  grinding  them  in  the 
usual  manner.  This  coffee  is  generally  given  as  an  adjunct  to  the  oH.  It 
is  esi^ecially  recommended  in  cases  where  there  exists  a  chronic  catarrh  of 
the  bowels.  Cold  bathing,  when  employed  with  proper  precautions  to  in- 
duce a  healthy  reaction,  is  of  vast  importance  in  the  treatment  of  many 
cases  of  scrofula.  These  precautions  ai'e  described  elsewhere  (see  Intro- 
duction). Cold  douching  is  most  useful  in  the  case  of  stout  children — those 
who  derive  Httle  benefit  from  cod-hver  oil. 

For  enlarged  scrofulous  glands,  besides  the  above  general  treatment, 
iodine  combined  with  iron  is  very  useful.  I  am  in  the  habit  of  prescribing 
iodide  of  potassium  -^ith  the  tartrate  of  ii*on  and  glycerine,  as  in  the  fol- 
lowing mixture  : 

5.  Potas.  iodidi 3_ij. 

Ferri  tartarati 3  j. 

Glyceriai §  ss. 

Acjuam  ad    3  iv. 

M.    Ft.     jMistura.     An  eighth  part  to  be  taken  three  times  in  the  day. 

The  iodide  should  be  given  in  fair  doses.  The  above  is  suitable  to  a 
child  of  five  years  of  age,  and  is  better  than  the  ordinaiT  syrup  of  the 
iodide  of  iron,  the  sugar  of  which  is  so  frequently  found  to  disagree. 
Some  practitioners  prefer  the  common  tincture  of  iodide,  given  in  doses  of 
three  or  four  drops  freely  diluted  with  water. 

Violent  attacks  of  dyspnoea  from  pressiu'e  of  enlarged  glands  upon  the 
nerves  of  the  chest  are  best  treated  at  the  time  by  strong  counter-irritants. 
After  the  attack  has  subsided  gentler  counter -initation  may  be  contuiued. 
I  have  thought  benefit  has  been  derived  from  the  careful  and  continued 
use  of  the  iodine  hniment  to  the  front  of  the  chest. 

Enlarged  cervical  glands  are  sometimes  reduced  by  rubbing  into  them 
twice  a  day  the  cadmium  ointment  of  the  British  Pharmacopoeia  diluted 
with  an  ec^ual  ciuantity  of  lai'd.  The  oleate  of  mercury  salve  is  also  of  ser- 
vice. This  apphcation  should  be  used  of  the  strength  of  five  per  cent.  It 
must  be  smeared  on  the  part,  not  rubbed  in."  It  can  be  used  twice  a  day 
for  the  first  five  days  ;  then  at  night  only,  and  afterwards  every  other  day. 
When  the  gland  suppin-ates  it  should  be  opened  with  as  little  delay  as 
possible,  in  order  to  avoid  unnecessary  scarring  of  the  skin.  It  is  im- 
portant, however,  to  anticipate  the  suppui-ative  process,  if  j)ossible,  and 
avoid  the  dangers  of  a  chronic  discharging  sore.  Therefore  if  the  meas- 
ures adopted  to  cause  absorption  are  seen  to  exert  little  influence  upon  the 
size  of  the  swelling,  it  is  advisable  to  call  in  the  aid  of  the  surgeon.  Dr. 
Clifford  Allbutt  strongly  advocates  free  incision  and  enucleation  of  the 
caseous  matter  ;  and  3,Ir.  Teale  states  that  he  has  successfully  treated 
many  such  cases  by  scooping  out  the  cheesy  contents  of  the  gland,  merely 
leaving  the  sound  portions  -with  the  enclosing  capsule. 


SCROFULA — TEEATMENT.  189 

If  softening  has  taken  place  and  the  abscess  formed  continues  to  dis- 
charge and  often  reinfiames,  the  nightly  administration  of  a  powder  con- 
taining one  grain  of  hydrargyi-um  cum  creta  to  eight  grains  of  peroxide 
of  u'on  is  often  attended  with  surprising  benefit.  This  powder  should 
not  be  given  longer  than  for  a  week  at  a  time.  The  sulphide  of  calcium 
in  doses  of  one-fifth  of  a  grain,  given  every  two  or  three  hours,  is  also  re- 
commended. This,  however,  is  a  very  uncertain  remedy.  Sometimes  it 
succeeds,  but  more  often  it  fails  completely.  The  chloride  of  calcium  in 
doses  of  five  grains  every  four  hours  is  sometimes  successful.  An  im- 
portant point  in  the  treatment  of  enlarged  cer^dcal  glands  is  warmth. 
During  the  whole  time  that  local  applications  are  being  used  the  swellings 
should  be  carefully  pi-otected  from  the  cold.  A  good  plsm  is-to  cover  them 
with  a  thick  pad  of  cotton-wool. 

Lugol '  has  si^oken  highly  of  iodine  in  all  forms  of  scrofulous  lesions. 
He  used  the  drug  as  a  salve  to  the  swelhngs,  as  a  lotion  to  the  ulcers,  as 
an  injection  to  the  sinuses  and  fistulous  sores,  and  as  a  bath  for  the  cure 
of  the  affections  of  the  skin  and  subcutaneous  tissues.  Iodine  tinctures 
and  ointments  are  still  favourite  apphcations  to  all  glandular  enlargements. 
They  should  be  used,  however,  with  caution.  I  have  seen  serious  slough- 
ing set  up  in  a  child's  neck  by  the  too  energetic  inunction  of  an  iodine 
ointment  into  the  skin  over  a  caseous  gland. 

Chronic  dischai'ges  from  the  various  mucous  surfaces  are  best  treated 
with  astringent  injections.  Otorrhoea  from  catarrh  of  the  auditory  mea- 
tus, if  hmited  to  the  part  outside  the  tymjpanum,  is  readily  cured  by  the 
following  lotion  : 

]J .  Boracis g^-  ^^ 

Zinci  sulphatis gr.  viij. 

Glycerini 3  j- 

Aquam  ad |  j. 

Misce. 

In  using  this  application  the  passage  must  be  first  thoroughly  cleansed 
by  injection  mth  warm  water,  and  then  half  a  drachm  of  the  lotion  must 
be  poured  into  the  ear  and  allowed  to  remain.  This  can  be  done  two  or 
three  times  a  day.  It  is  important  to  cure  a  discharge  from  the  ear  as 
quickly  as  possible.  The  old  notion  that  otorrhoea  in  children  should  not 
be  checked  too  quickly  is  one  which  if  acted  upon  may  have  serious  con- 
sequences. 

^  The  strength  recommended  by  Lugol  for  his  salve  was : 

IJ .  lodinii gr.  vj.  -x. 

Potas.  iodidi 3  ij.-iv. 

Adipis , 3  j. 

Misce. 
For  his  lotion  or  injection : 

B .  lodinii gr.  j.-lj. 

Potas.  iodidi gr.  ij.-iv. 

Aq.  destillatse |  viij. 

Misce. 
For  his  hath,  for  the  use  of  a  child  : 

I^.  lodinii 3ij. 

Potas.  iodidi 3  iv. 

Aq.  destillatse q-  s. 

Dissolve  completely  and  add  to  three  gallons  of  water  of  the  temperature  of  98'  F. 
in  a  wooden  vessel.  This  same  solution  he  recommends  as  a  fomentation  to  scrofu- 
lous lesions  and  sores. 


CHAPTEE  11. 

ACUTE  TUBEECULOSIS, 

Acute  tuberculosis  is  an  acute  febrile  general  disease  which  arises,  in 
most  cases,  as  a  consequence  of  special  hereditary  predisposition.  The  dis- 
ease expresses  itself  anatomically  by  the  formation  of  the  miliary  nodule 
known  as  the  gray  granulation  in  the  various  organs  of  the  body.  This 
nodule  is  in  great  part  an  out-growth  from  the  lymphatic  system,  and  may 
be  found  wherever  lymphatic  or  adenoid  tissue  normally  exists.  Acute 
tuberculosis  is  not  to  be  confounded  with  pulmonary  phthisis.  Indeed, 
the  two  affections  are  essentially  distinct,  for  ulceration  of  the  lung,  al- 
though occasionally  present,  is  by  no  means  a  necessary  part  of  the  tuber- 
cular process. 

In  the  young  subject  acute  tuberculosis  frequently  assumes  a  form 
which  is  rare  in  the  adult.  In  childhood  the  disease  not  uncommonly 
presents  itseK  as  a  primary  febrile  affection,  giving  rise  to  but  few  symp- 
toms, and  those  the  manifestation  merely  of  the  general  distress  without 
any  sign  pointing  to  local  mischief.  It  is  often  not  until  a  few  days  be- 
fore the  close  of  the  illness  that  any  symptoms  are  discovered,  to  draw  at- 
tention to  any  particular  organ.  This  is  the  primary  form  of  the  disease, 
which  has  much  the  character  of  an  acute  specific  fever. 

In  other  cases,  almost  at  the  same  time  with  the  beginning  of  the  gen- 
eral symptoms,  others,  more  or  less  severe,  are  noticed,  showing  that  some 
particular  organ  is  especially  fastened  upon  by  the  tubercular  process. 
This  form  is  not  uncommon  in  cases  of  tubercular  meningitis. 

A  third  form  resembles  that  which  is  often  met  with  in  the  adult  where 
the  disease  aiises  as  a  secondary  affection  in  the  course  of  some  other  ill- 
ness, and  in  such  a  case  brings  the  life  of  the  child  quickly  to  an  end. 
This  form  is  seen  when  tuberculosis  supei-venes  upon  empyema,  pneumo- 
nic phthisis,  etc. 

Acute  tuberculosis  attacks  children  of  all  ages,  and  may  be  seen  in  very 
young  infants.  When  it  occurs  at  this  early  age  the  anatomical  feature  of 
the  disease  is  always  very  widely  distributed.  On  the  other  hand,  the 
older  the  child  the  more  likely  is  it  that  the  formation  of  the  gray  granu- 
lation will  be  limited  to  special  cavities  of  the  body. 

The  word  "  tubercle  "  has  been  and  is  stiU  employed  in  so  vague  a 
sense  by  various  authors  that  it  has  almost  ceased  to  convey  any  definite 
meaning.  It  may  be  well,  therefore,  to  state  that  in  the  following  pages 
the  word  is  in  every  case  used  to  signify  the  miliary  nodule  called  "gray 
granulation  "  in  the  adult,  but  which  in  the  child  very  quickly  becomes 
yeUow  and  opaque. 

Causation. — Hereditary  predisposition  plays  a  very  important  part  in 
the  etiology  of  tuberculosis.  In  a  large  proportion  of  cases  a  distinct 
family  tendency  to  the  formation  of  tubercle  can  be  discovered.  The  ten- 
dencyis  not,  however,  always  exhibited  in  the  parents.     These  are  often,  to 


ACUTE  TUBERCULOSIS — CAUSATIOIT.  "  191 

all  appearances,  of  sound  constitution.  It  may  be  necessary  to  push  our 
inquiries  farther  back  and  ask  as  to  the  health  of  the  grandparents  and  of 
collateral  branches  of  the  family.  In  a  child  with  this  unfortunate  predis- 
position, any  cause  which  impairs  the  nutrition  of  the  body  may  excite  the 
manifestations  of  the  tubercular  tendency.  Therefore  lowering  complaints 
and  insanitary  conditions  generally  are  justly  regarded  as  important  agents 
in  the  production  of  tuberculosis. 

There  are  certain  acute  specific  maladies  with  which  the  tubercular  for- 
mation is  very  apt  to  be  associated.  Whooping-cough  and  measles  may 
be  said  to  number  tuberculosis  amongst  their  sequelae,  so  common  is  it  to 
find  children  convalescent  from  these  complaints,  who  are  placed  under 
unfavourable  conditions  for  complete  recovery,  fall  victims  to  the  disease. 
Typhoid  fever  is  sometimes  followed  by  it.  Children  who  suffer  from  mal- 
formation of  the  heart  with  narrowing  of  the  pulmonary  artery  are  also 
very  liable  to  become  tubercular.  They  do  not,  however,  often  suffer  from 
acute  tuberculosis.  In  them  the  disease  is  more  apt  to  assume  primarily 
the  form  of  chronic  tubercular  phthisis,  even  if  the  distribution  of  tuber- 
cle become  afterwards  generalised.  When  the  predisposition  is  strong, 
any  cause  which  gives  a  shock  to  the  system,  such  as  a  fall,  a  blow,  or 
other  similar  accident,  may  be  sufficient  to  excite  the  outbreak  of  the  dis- 
ease. 

In  addition  to  the  cases  where  tuberculosis  is  excited  in  the  bodies  of. 
persons  predisposed  to  the  affection  by  febrile  disturbances  or  unwhole- 
some conditions  of  life,  there  are  other  instances  where  the  disease  appears 
to  be  set  up  by  a  local  infective  process.  It  has  been  weU  established 
by  numerous  experimenters  that  the  inoculation  of  tuberculous  matter 
into  the  bodies  of  healthy  animals  will  produce  general  tuberculosis  ; 
and  it  is  held  by  Koch  and  his  followers  that  the  infecting  agent  in 
such  cases  is*  the  minute  organism  knov^Ti  as  the  "tubercle  bacillus."  Un- 
til lately  it  was  beheved  that  the  inoculation  into  a  healthy  animal  of 
non-tuberculous  or  putrid  matters  would  give  rise  to  the  formation  in  the 
system  of  a  body  indistinguishable  by  the  microscope  from  the  gray  granu- 
lation. But  recent  investigations  have  made  it  evident  that  some  fallacy 
must  have  been  present  in  the  experiments  which  appeared  to  establish 
this  result ;  for  a  repetition  of  the  experiments  by  competent  observers 
have  shown  that  no  ill  consequences  of  any  kind  may  follow  the  intro- 
duction of  such  matters  under  the  skin.  Still,  arguments  drawn  from 
experiments  upon  animals,  especially  upon  the  rodentia,  which  are  usually 
selected  for  these  investigations,  are  not  perhaj)s  strictly  applicable  to  the 
human  subject.  In  man  the  presence  of  softening  cheesy  matter  in  any 
part  of  the  body  may  set  up  an  infective  process  which  is  indicated  by 
fever,  wasting,  and  symptoms  of  general  distress,  and  eventually  by  signs 
indicating  implication  of  special  organs.  After  death  a  general  distribu- 
tion of  small  nodules  which  have  all  the  characters  of  the  gray  granulation 
is  found  in  various  organs.  In  children  a  chronic  empyema  often  induces 
such  a  condition,  and  the  cliild  usually  dies  with  the  symptoms  of  tuber- 
cular meningitis.  Acute  tuberculosis  may  be  also  set  up  by  other  forms 
of  cheesy  degeneration.  Softening  caseous  glands  and  cheesy  pneumonia 
are  common  exciting  causes  of  the  disease  ;  indeed,  the  scrofulous  habit  of 
body  appears  in  itself  to  be  a  favouring  influence,  and  the  tissues  of  such 
subjects  furnish  a  congenial  soil  in  wliich  the  growth  of  the  tubercular 
bodies  can  be  readily  excited.  The  share  taken  by  the  tubercle  baciUvis  in 
the  production  of  tuberculosis — whether  it  is  the  sole  medium  by  which 
the  infection  is  conveyed,  as  is  maintained  by  some,  or  is  merely  a  casual 


192  DISEASE   IjST    CHILDRElSr. 

addition  to  the  septic  agent,  as  is  believed  by  others — is  still  at  the  pres- 
ent moment  a  matter  of  warm  debate. 

Morbid  Anatomy. — The  distribution  of  the  gray  granulation  is  very 
frequently  general  in  the  child.  In  the  infant  it  is  almost  always  so  :  in 
older  children  it  may  be  hmited  to  one  or  more  cavities  of  the  body. 
MM.  Eilliet  and  Barthez  have  commented  upon  the  curious  fact  that  while 
in  the  adult,  according  to  Louis'  canon,  if  tubercle  exist  anywhere  in  the 
body  it  will  be  found  also  in  the  lungs,  in  the  child  the  lungs  sometimes 
escape  altogether  although  every  other  part  of  the  body  is  attacked. 
When  found  in  one  cavity  of  the  body  alone,  the  part  affected  is  usually 
the  skull  or  the  abdomen. 

The  gray  granulation  is  a  firm,  gray,  transliicent,  projecting  nodule 
which  varies  in  size  from  a  fine  pin's  head,  or  even  a  smaUer  object,  to  a 
millet  seed.  In  children  the  colour  very  quickly  changes  to  yellow  and 
the  translucence  disappears,  so  that  whatever  organ  is  examined  gray  and 
yellow  nodules  (the  latter  usually  predominating)  are  found  mixed  to- 
gether. The  growth  occurs,  according  to  Rindfleisch,  as  the  result  of  a 
specific  initation  of  the  endothelia  of  the  lymjohatics,  the  serous  mem- 
branes, and  the  blood-vessels,  especially  the  former ;  and  the  nodules  are 
found  to  follow  the  ramifications  of  the  finer  arteries  because  the  lympha- 
tics run  chiefly  in  the  adventitia  of  the  blood-vessels.  On  careful  exami- 
nation the  miliary  bodies  can  be  seen  growing  upon  the  fine  vessels,  in- 
volving the  whole  calibre  of  the  channel  in  the  smallest  arteries,  and  in 
those  a  degree  larger  forming  protuberances  on  one  side.  Rindfleisch  de- 
scribes the  granule  as  a  product  of  inflammation,  and  states  that  it  consists 
in  an  increasing  accumulation  of  leucocytes  in  the  connective  tissue  of  the 
part  irritated.  Of  these  white  cells  a  portion  take  on  an  epithelioid  char- 
acter. These  grow  to  three  or  five  times  the  size  of  a  white  blood  corpus- 
cle and  are  called  tubercle  cells.  Others  develojD  into  the  irregular 
branching  bodies  called  "  giant-ceUs."  The  giant-cells  are  not,  however, 
as  was  at  one  time  supposed,  pecuHar  to  tubercle.  Schilppel  believes  that 
they  arise  within  a  blood-vessel  fi'om  the  accumulation  and  adhesion  of 
tenacious  masses  of  molecular  matter.  "When  they  have  reached  a  size 
which  causes  distention  of  the  vessel,  nuclei  begin  to  appear.  According 
to  this  observer,  the  epithelioid  cells  are  derived  from  processes  of  the 
giant-cells.  They  lie  around  the  latter  and  constitute  the  greater  j)art  of 
the  nodule.  According  to  most  observers,  a  section  of  the  tubercles,  after 
they  have  been  some  time  in  existence,  shows  a  dehcate  reticiilum,  the 
meshes  of  which  contain  the  cells.     This,  however,  is  denied  by  others. 

In  proportion  as  the  tubercular  body  enlarges  by  accumulation  of  cells 
the  central  part  is  found  to  degenerate,  and  when  examined  at  this  stage 
{i.e.,  after  degeneration  has  begun)  itwiU  be  seen  to  consist  in  great  meas- 
lu^e  of  small,  shrivelled,  and  granular  cells. 

The  presence  of  the  gray  granulation  in  any  tissue  is  usually  quickly 
followed  by  inflammation  in  the  neighbourhood  of  the  growths.  In  the 
case  of  a  serous  membrane,  such  as  the  meninges  of  the  brain  or  the  peri- 
toneum, lymph  is  quickly  thrown  out,  and,  if  time  be  allowed,  becomes 
caseous.  In  the  lungs  an  early  consequence  is  bronchitis  and  catarrhal 
pneumonia.  In  these  organs  the  granules  very  quickly  become  yeUow  and 
caseous,  and  eyerj  stage  of  degeneration  of  the  nodules  is  usually  to  be 
discovered.  Dr.  Wilson  Fox  has  described  in  the  lungs  of  children  dead 
from  tuberculosis  :  gray  translucent  granulations  ;  opaque  white  gran- 
ules— soft,  but  of  vai'jdug  firmness  and  resistance  ;  the  same,  but  caseous 
in  the  centre ;  yellow  granulations,  very  soft  and  easily  crushed  ;  cheesy 


ACUTE   TUBERCULOSIS — MORBID   ANATOMY.  193 

granules — dry,  opaque,  and  friable,  witli  or  without  a  surrounding  zone  of 
gray  transparent  matter ;  gToups  of  the  latter  forming  httle  masses  the 
size  of  a  pea,  bean,  or  even  walnut ;  indurated  pigmented  granules,  single 
or  in  groups  ;  and,  lastly,  tracts  of  variable  size  and  irregular  outline, 
granular  on  the  surface,  passing  insensibly  into  the  so-called  "  gray  infil- 
tration." Sometimes,  also,  he  noticed  little  cavities  from  softening  of  the 
tubercular  masses.  There  were,  in  addition,  signs  of  secondary  catarrhal 
pneumonia  and  its  consequences. 

Ulceration  of  lung  and  the  formation  of  cavities  is  not  a  common  con- 
sequence in  early  life  of  acute  pulmonary  tuberculosis.  In  infants  in  whom 
the  disease  runs  a  rapid  course  this  lesion  is  very  exceptional.  It  is,  how- 
ever, sometimes  met  with.  Thus,  in  an  infant,  aged  eight  months,  with 
four  teeth,  who  died  in  the  East  London  Children's  Hospital  of  acute  gen- 
eral tuberculosis  with  secondary  broncho-pneumonia  and  meningitis,  tu- 
bercles, gray  and  yeUow,  were  found  after  death  occupying  all  the  cavities 
in  the  body.  They  were  discovered  at  the  base  of  the  brain,  on  the  peri- 
toneum, in  the  substance  of  the  liver,  spleen,  and  kidnej^s.  The  lungs  were 
completely  stuifed  with  them,  and  in  the  lower  lobe  of  the  left  lung  a  small 
cavity  had  formed  of  the  size  of  a  hazel-nut.  Such  a  condition  is,  however, 
not  common.  Even  in  older  children,  although  the  duration  of  the  illness 
is  longer,  breaking  up  of  the  lungs,  as  a  consequence  of  acute  tuberculosis 
is  comparatively  rarely  seen. 

In  the  intestines  the  gray  and  yellow  granulations  are  seated  especially 
in  the  smaller  bowel,  and  involve  principally  the  ihum  and  the  part  of  the 
csecum  in  the  neighbourhood  of  the  valve.  The  nodules  he  in  the  sub- 
mucous tissue,  and  in  the  acute  form  of  the  disease  do  not,  as  a  rule,  give 
rise  to  ulceration.  In  the  liver  the  tubercles  are  developed  on  the  smallest 
ramifications  of  the  hepatic  artery.  They  may  be  seen  under  the  serous 
coat,  and  are  also  found  in  the  interlobular  spaces  and  in  the  interior  of 
the  lobules.  They  are  usually  few  in  number.  In  addition  to  being  the 
seat  of  tubercle,  the  organ  is  often  found  to  jDresent  other  pathological 
characters  not  especially  distinctive  of  the  tubercular  disease.  Thus,  it 
may  be  enlarged  from  a  simple  hypertrojjhy  or  from  fatty  infiltration,  and 
is  sometimes  the  seat  of  a  cirrhotic  change.  In  the  latter  case  it  may  give 
rise  to  ascites. 

The  spleen  is  one  of  the  organs  most  commonly  attacked  by  tubercle. 
Gray  and  yellow  granulations  and  large  cheesy  masses  may  be  found,  so 
that  the  size  of  the  organ  is  considerably  increased.  In  the  kidneys  mili- 
ary nodules  may  be  thinly  scattered  through  the  parenchyma.  The  little 
masses  are  developed,  as  elsewhere,  in  the  sheath  of  the  smallest  arteries. 
Sometimes  more  extensive  disease  is  met  with,  and  large  masses  of  cheesy 
matter  are  formed  which  soften  and  give  rise  to  tuberculous  ulcers.  These- 
may  penetrate  deeply  into  the  renal  tissue.  According  to  Rindfleisch  the 
disease  begins  in  the  papillary  portion  of  the  gland,  spreading  from  the 
mucous  lining  of  the  calices.  In  extreme  cases  the  kidney  is  converted 
into  a  thick-walled  sac,  with  hemispherical  protrusions,  each  of  which  cor- 
responds to  a  Malpighian  pyramid.  The  bladder  is  sometimes  involved,  al- 
though comparatively  rarely  in  early  life.  Mihary  nodules  appear  in  the 
submucous  tissue  and  soften,  giving  rise  to  circular  ulcers  the  edges  of 
which  are  found  on  examination  to  be  infiltrated  with  closely  jDacked  gray 
and  yeUow  granulations. 

In  addition  to  the  lesions  which  have  been  mentioned,  the  bronchial 
and  mesenteric  glands  are  always  enlarged  and  cheesy.  Sometimes  they 
are  softened. 

13 


194  DISEASE   IN   CHILDEEN. 

How  far  the  cheesy  matter,  which  is  often  found  in  large  quantities  in 
the  more  prolonged  cases  of  pulmonary  tuberculosis,  is  to  be  i-egarded  as 
tubercular  is  a  question  upon  which  opposite  opinions  are  held.  Virchow 
and  his  followers  look  upon  all  such  caseous  matter  as  the  consequence  of 
catarrhal  pneumonia  ;.  and  there  is  no  doubt  that  the  miliary  nodule  is 
primarily  an  extra-alveolar  growth,  while  the  caseous  masses,  such  as  are 
found  in  cheesy  pneumonia,  take  their  origin  from  a  proliferation  of  the 
epithehal  elements  in  the  au'-cells.  Before  the  giant-cell  was  known  to 
be  a  constituent  of  other  than  strictly  tubercular  structures,  the  presence 
of  this  cell  was  held  to  be  confirmatory  of  the  tubercular  natui'e  of  the 
pathological  product.  Now  the  presence  of  the  bacillus  is  considered  by 
many  to  point  to  the  same  conclusion.  But  is  the  question  one  which  can 
be  determined  solely  upon  anatomical  grounds  ?  The  clinical  history  of 
the  disease  is  surely  a  not  unimportant  element  in  the  solution.  It  is  gen- 
erally admitted  that  the  closest  examination  discovers  in  the  gray  granula- 
tion no  peculiarity  of  structure  which  can  be  relied  upon  to  separate  the 
nodule  from  other  bodies  having  a  like  apj)earance,  and  under  the  micro- 
scope all  cheesy  matter  has  very  similar  characters.  The  case  is  one  in 
which  the  clinical  features  of  the  malady  should  have  an  exceptional  value 
in  determining  the  nature  of  the  pathological  product ;  for  if  two  diseases 
are  found  to  difter  widely  in  the  mode  of  origin  of  the  attack,  in  the  nature 
of  the  symptoms,  and  in  the  course  of  the  illness,  we  may  hesitate  to  ad- 
mit identity  of  nature,  however  close  may  be  the  resemblance  in  the  ana- 
tomical conditions. 

Symptoms. — Primary  tuberculosis  in  the  child  commonly  assumes  the 
form  of  an  acute  general  disease.  It  excites  moderate  pyrexia  and  marked 
interference  with  nutrition,  and  from  the  indefinite  character  of  the  earlier 
symptoms  and  the  absence  of  any  manifestation  of  local  distress,  often 
presents  great  difficulty  in  the  diagnosis.  Sooner  or  later  signs  are  dis- 
covered pointing  to  disease  of  special  organs:  cerebral  symptoms  arise, 
or  there  are  indications  of  pulmonary  mischief.  Tubercular  meningitis 
and  cerebral  tubercle  are  described  at  length  in  special  chapters.  The 
present  descrii^tion  is  confined  to  cases  where  the  disease  is  general,  and 
where  the  local  symptoms  are  limited  to  the  lungs  and  other  organs  not 
elsewhere  referred  to. 

Children  v/ho  fall  victims  to  acute  tuberculosis,  although  often  of  deh- 
cate  appearance,  are  not  necessarily  thin  and  feeble-looking.  In  many 
cases  the  nutrition  of  the  patient  is  very  good,  and  the  child  is  considered 
to  be  in  every  way  a  healthy  subject  until  the  disease  appears.  It  is  not 
at  all  uncommon,  especially  in  cases  where  the  chief  violence  of  the  malady 
is  expended  upon  the  cerebral  meninges,  to  find  that  up  to  the  time  of  his 
illness  the  child  had  never  suffered  from  a  day's  indisposition.  In  o'ther 
cases  the  patient  has  been  noticed  to  be  sensitive  to  chills  and  prone  to  at- 
tacks of  indigestion.  These  latter  children  are  often  of  frail  appearance 
and  have  the  "tubercular  aspect."  Their  skin  is  thin  and  transparent, 
their  hair  fine  and  silky,  their  features  regular  and  delicate,  theii-  bones 
small,  and  their  shoulders  narrow  and  sloping. 

Acute  tuberculosis  may  begin  gradually  or  suddenly.  In  exceptional 
cases  the  disease  has  an  abrupt  beginning.  There  is  high  fever,  headache, 
epistaxis,  relaxed  or  confined  bowels,  and  the  child  is  very  restless  and 
stupid.  But  this  mode  of  beginning  is  very  rare.  In  the  lai-ge  majority 
of  instances  the  onset  is  so  insidious  that  there  is  a  difficulty  in  fixing  uj)on 
a  date  for  the  beginning  of  the  attack.  The  earlier  symptoms,  as  has  been 
said,  are  so  slight  and  vague,  and  the  child  passes  so  gradually  from  health 


ACUTE   TUBEKCULOSIS — SYMPTOMS.  195 

to  sickness,  that  the  mother  is  iisually  quite  unable  to  determine  when 
she  first  noticed  any  signs  of  indisposition.  She  will  say  that  for  some 
weeks  the  child  had  seemed  to  be  less  brisk  and  lively  than  was  his  wont ; 
that  he  would  often  lie  about  instead  of  playing  ;  and  that  his  appetite 
had  seemed  to  fail ;  but  that  no  special  importance  was  attached  to  these 
symptoms  until  something  more  definite  was  noticed  which  excited  alarm. 
The  first  influence  of  the  disease  is  upon  general  nutrition.  The  child  be- 
gins to  look  pale,  with  a  curious  transparent  pallor.  His  conjunctivae  have 
a  bluish  tint,  and  the  lower  eyelid  is  discoloured.  He  loses  his  sprightli- 
ness  and  gets  dull  and  moping ;  his  appetite  is  poor,  and  he  falls  off  in  his 
flesh.  A  certain  amount  of  fever  usually  accompanies  this  condition.  In 
the  evening  the  cheeks  may  be  brightly  flushed,  and  the  hands  and  feet 
feel  hot  to  the  touch.  At  this  time  a  thermometer  in  the  axilla  marks  be- 
tween 100°  and  101°.  The  patient  is  thirsty,  and  often  asks  for  Avater  in 
the  night.  In  the  morning  the  temperature  is  normal  ;  but  the  child  when 
he  leaves  his  bed  generally  looks  pale  and  distressed.  The  anxious  ex- 
pression of  the  face  in  these  cases  is  indeed  commonly  a  noteworthy  phe- 
nomenon ;  and  if  combined  with  mildness  of  the  general  symptoms,  and 
complete  absence  of  all  signs  of  local  discomfort,  is  an  indication  of  illness 
of  very  serious  moment.  In  some  cases  there  are  repeated  attacks  of  chilli- 
ness followed  by  heat  ;  and  these  may  have  a  periodicity  which  suggests 
suspicions  that  the  child  is  suffering  from  ague.  The  chilliness,  however, 
seldom  amounts  to  shivering,  and  sweating  is  scanty  or  absent.  Loss  of 
flesh  is  never  very  long  in  showing  itself.  The  wasting  is  often  very 
gradual,  unless  some  relaxation  of  the  bowels  is  present,  and  in  the  major- 
ity of  cases  is  intermittent.  In  hospital  patients,  under  the  unaccustomed 
influence  of  good  food  and  nursing,  it  is  not  uncommon  for  a  child  to  re- 
gain some  of  the  flesh  he  had  lost,  although  all  the  time  the  fever  con- 
tinues and  the  general  disease  is  pursuing  its  regular  track.  Even  in 
children  who  are  living  in  better  circumstances  the  progress  of  the  illness 
is  often  very  unequal — the  child  seeming  to  be  alternately  better  and 
worse,  and  the  temperature  fluctuating  curiously  from  day  to  day.  Some- 
times, indeed,  the  pyrexia  is  found  entirely  to  subside,  and  for  a  few  days 
the  improvement  may  be  such  that  recovery  is  confidently  anticipated. 
The  intermission  is  usually,  however,  of  short  duration,  and  the  patient 
relapses  into  his  former  state.  At  this  time  a  common  symptom  is  oedema 
of  the  legs  and  sometimes  of  the  face,  and  the  luine  may  contain  a  trace 
of  albumen.  In  young  babies  the  only  symptoms  of  the  disease  for  a  con- 
siderable time  may  be  slight  fever,  pallor,  some  loss  of  flesh,  an  inelastic 
state  of  the  skin,  and  a  little  oedema  of  the  extremities. 

For  the  first  few  weeks  the  above  general  symptoms  are  all  that  can  be 
discovered  ;  and  the  most  careful  examination  detects  no  cause  to  which 
the  evidently  serious  condition  of  the  child  can  be  referred.  He  is  thin, 
pale,  weakly,  and  listless  ;  but  his  tongue  is  clean,  and  although  feverish 
and  restless  at  night,  he  sleeps  fairly  well,  is  not  light-headed,  and  in  the 
daytime  makes  no  complaint.  His  abdomen  is  normal,  rather  flattened 
than  distended  ;  there  is  no  enlargement  of  the  liver  or  spleen — at  least 
during  the  first  few  weeks  of  the  illness  ;  and  pressure  of  the  beUy  elicits 
no  sign  of  tenderness.  In  some  cases  a  few  rosy  spots,  rather  more  red 
than  the  typhoid  spot,  and  of  a  larger  size,  are  noticed  on  the  abdomen 
and  chest.     The  skin  generally  is  dry  and  harsh. 

After  a  time  local  symptoms  arise.  These  often  point  to  cerebral  ii'ri- 
tation.  An  attack  of  convulsions  occurs,  followed  by  squinting  ;  the  pupils 
are  dilated  ;  there  is  drowsiness  and  rigidity  of  joints  ;  and  the  child  dies 


196  DISEASE   IN   CHILDEEliJ-. 

with  all  the  symptoms  of  tubercular  meningitis.  It  other  instances  the 
cranial  cavity  escapes,  and  symptoms  are  noticed  showing  implication  of 
the  lungs. 

The  first  local  sign  of  acute  pulmonary  tuberculosis  is  cough.  This  is 
short  and  hacking,  and  in  the  earlier  period  not  very  frequent.  It  may 
be  accompanied  by  some  hurry  of  breathing  ;  but  the  respirations  are  not 
alwa^'s  increased  in  rapidity,  and  even  at  an  advanced  stage  of  the  disease, 
if  there  be  only  a  moderate  amount  of  catarrh,  may  be  little,  if  at  all 
more  rapid  .than  in  health.  The  cough  at  this  time  is  not  accompanied  by 
any  abnormalit}^  of  physical  signs.  Eepeated  examination  of  the  chest 
discovers  no  dulness  on  percussion  ;  and  an  occasional  click  of  rhonchus 
or  a  sibilant  wheeze  may  be  the  only  phenomenon  present.  In  some  cases 
the  child  dies  without  any  fresh  symptoms ;  but  usually  a  secondary  bronchi- 
tis develops  after  a  time.  The  breathing  then  becomes  rajDid,  the  face  is 
haggard  and  livid,  and  the  nares  dilate  in  inspiration.  The  pulse  is  small 
and  rapid,  and  there  may  be  some  slight  perversion  of  the  pulse-respira- 
tion ratio  ;  but  this  never  occurs  to  the  degree  noticed  in  cases  of  broncho- 
pneumonia. The  temperature  rises,  and  may  reach  103°  in  the  evening, 
sinking  to  100°  in  the  morning.  With  the  stethoscope  we  now  find  the 
breath-sounds  covered  by  a  crisp,  bubbling  rhonchus,  which  occupies  the 
whole  extent  of  both  inspiration  and  expiration.  If  the  breathing  can  be 
heai'd  through  the  rhonchus,  it  is  not  bronchial  although  the  expiration 
is  perhaps  prolonged.  There  is  no  duhiess  if  collapse  be  absent ;  but 
sometimes  local  collapse  of  small  extent  occtu'S  at  the  apex  ;  and  we  may 
find  a  little  local  dulness  at  the  supra-spiuous  fossa,  or  above  the  clavicle, 
with  faint  bronchial  breathing.  There  is  nowhere  any  increased  resonance 
of  voice  or  cough. 

The  above  signs  may  persist  without  alteration  to  the  close.  Often, 
however,  the  inflammation  passes  into  catan-hal  pneumonia.  Patches  of 
dulness  are  then  discovered  at  the  apex  or  elsewhere.  At  these  spots  the 
breathing  is  blowing  or  tubular  ;  the  rhonchus  becomes  crisper,  finer,  and 
more  crepitating  in  character  ;  and  the  vocal  resonance  may  be  intensely 
bronchophonic.  The  patches  of  consolidation,  as  in  cases  of  the  non- 
tubercular  inflammation,  may  coalesce  until  large  areas  of  tissue  are  solid- 
ified. 

The  occurrence  of  broncho-pneumonia  is  also  indicated  by  increased 
severity  of  the  previous  symptoms.  The  lividity  deepens ;  the  breathing 
becomes  laboured  ;  the  soft  parts  of  the  chest  and  epigastrium  sink  in  at 
each  inspiration  ;  the  nails  become  purple,  and  the  superficial  veins  of  the 
extremities  are  fuUer  than  in  health.  The  temperature  also  rises  to  a 
higher  level,  and  may  reach  104°  or  105°  in  the  evening.  When  these 
symptoms  are  noticed  the  illness  is  very  near  its  close  ;  indeed,  the  child 
seldom  survives  longer  than  a  day  or  two.  Death  may  be  preceded  by  a 
fit  of  convulsions,  due  either  to  meningitis  or  asphyxia. 

A  little  gu'l,  aged  ten,  with  a  consumptive  family  history,  was  a  pa- 
tient in  the  East  London  Children's  Hospital.  The  child  was  said  to  have 
suflered  when  quite  young  from  measles,  whooping-cough,  and  scarlatina, 
but  had  recovered  perfectly  from  each,  although  the  latter  had  been  fol- 
lowed by  dropsy.  She  had  also  had  an  attack  of  ague  when  between  two  and 
three  years  of  age.  Still,  the  child  had  been  in  fau-  health  until  six  weeks 
before  admission.  Her  illness  had  begun  suddenly,  but  the  symptoms  at 
first  were  not  marked.  She  had  seemed  generally  poorly,  but  did  not  lose 
flesh  to  any  considerable  extent ;  nor  was  she  troubled  with  cough  for  the 
first  three  weeks.     When  the  cough  began  it  was  short  and  dry,  but  not 


ACUTE   TUBERCULOSIS — SYMPTOMS/  197 

distressing.  Three  days  before  admission  it  had  become  loose,  and  the 
child  had  expectorated  some  yellow  phlegm.  After  the  cough  began  she 
was  noticed  to  waste  and  to  be  feverish,  sweating  much  at  night.  For  a 
week  her  feet  had  been  a  little  swollen. 

On  admission  the  child's  expression  was  anxious.  There  was  some 
lividity  of  the  face,  and  in  the  evening  her  cheeks  flushed  brightly.  Her 
tongue  was  clean  and  her  bowels  regular.  Temperature  at  7  p.  m.,  100.4°. 
On  examination  of  the  chest  the  percussion-note  was  slightly  high-pitched 
above  the  clavicles,  but'  elsewhere  was  normal.  Everywhere  about  the 
chest  the  breath-sounds  were  concealed  by  a  metallic  bubbling  rhonchus. 
This  was  coarser  behind  than  in  front,  and  occupied  the  whole  extent  of 
both  inspiration  and  expiration.  The  vocal  resonance  was  normal.  A 
rhonchal  fremitus  could  be  felt  everywhere  about  the  chest. 

After  admission  the  physical  signs  persisted  with  little  alteration.  The 
didness  disappeared  from  the  apices  and  none  could  be  detected  elsewhere. 
The  pulse  was  very  rapid,  150-168  ;  respirations,  60-68  ;  temperature  each 
evening,  101°~102.4°.  After  a  few  days  the  lividity  deepened  ;  the  child 
became  very  restless,  and  she  died  on  the  ninth  day — the  fifty-first  day  of 
her  illness. 

On  examination  of  the  body  gray  or  yellow  miliary  nodules  were  found 
in  the  Hver,  spleen,  and  kidneys.  Gray  granulations  were  also  seen  under 
the  serous  coat  of  the  small  intestine,  and  were  numerous  on  the  pia  ma- 
ter. The  lungs  were  stuffed  with  tubercle  throughout,  and  the  nodules 
formed  projections  on  the  surface  underneath  the  pleura.  The  nodules 
varied  in  size,  the  largest  not  exceeding  a  hemp-seed  in  diameter.  The 
lung  tissue  between  them  was  of  a  deep  red  colour  and  tore  readily.  It, 
however,  floated  in  water.  The  mediastinal  glands  were  enlarged  and 
cheesy,  and  one  or  two  were  softened. 

Besides  the  parts  which  have  been  mentioned,  tuberculosis  sometimes 
involves  the  urinary  apparatus.  The  kidneys  indeed  are  often  affected,  and 
the  consequent  congestion  is  no  doubt  a  cause  of  the  sHght  albuminuria 
which  is  a  common  symptom  of  the  affection.  But  besides  the  kidneys, 
tuberculosis  may  occur  in  the  bladder.  Tliis  lesion  is  more  common  in 
the  adult  than  in  younger  subjects,  but  is  met  with  from  time  to  time  in 
the  older  children.  As  it  gives  rise  to  many  of  the  symptoms  of  vesical 
calculus  this  form  of  tuberculosis  must  not  be  passed  over  without  a  word 
of  mention. 

The  presence  of  mUiary  tubercles  in  the  bladder  sets  up  a  cystitis,  and 
gives  rise  to  symptoms  which  are  attributed  almost  invariably  to  stone. 
There  is  great  irritability  of  the  bladder  and  increased  frequency  of  mictu- 
rition ;  and  according  to  Guebeard,  these  symptoms  are  more  marked  at 
night  than  during  the  day.  At  the  end  of  the  flow  of  urine  some  pus  may 
be  passed,  or  a  drop  of  blood  may  appear  at  the  extremity  of  the  urethral 
canal.  There  may  be  pain,  which  is  referred  to  the  region  of  the  bladder, 
and  the  passage  of  urine  is  often  accompanied  by  uneasiness.  Sometimes 
micturition  is  only  effected  by  straining,  during  which  the  rectum  may  pro- 
lapse. The  urine  may  be  normal,  but  often  is  cloudy  and  thick.  It  may 
contain  a  trace  of  albumen.  The  temperature  and  general  symptoms  of 
tuberculosis  are  present  in  these  cases.  Exploration  of  the  bladder  with  a 
sound  discovers  no  calculus  ;  but  digital  examination  by  Volkmann's 
method  [i.e.,  passing  a  finger  into  the  rectum  and  palpating  mtli  the  other 
hand  above  the  pubes)  sometimes  detects  a  tubercular  nodule  at  the  fun- 
dus of  the  bladder. 

In  the  stomach,  intestine,  liver,  and  spleen  the  development  of  tubercle 


198  DISEASE   I]Sr   CHILDREN. 

rarely  gives  rise  to  sufficient  local  symptoms  ^o  fiuiiisli  grounds  for  diag- 
nosis. In  the  stomach  the  lesion  may  excite  digestive  trouble  ;  but  even. 
this  is  an  uncommon  consequence  of  the  disease,  and  when  present  is  sig- 
nificant merely  of  catarrh  of  the  mucous  membrane.  Bignon,  indeed,  has 
reported  a  case  in  which  a  child  died  after  vomiting  a  large  quantity  of 
blood,  and  on  examination  of  the  body  an  ulcer  was  found  at  the  larger 
curvature  surrounded  by  tuberculous  nodules.-  This  case  is,  however,  a 
very  exceptional  one.  In  the  mtestine  the  lesion  seems  to  excite  no  symp- 
toms whatever.  The  spleen,  if  thronged  wdth  maisses  of  tubercle,  may  be 
enlarged  ;  but  the  liver  is  rarely  increased  in  size  from  this  cause.  It  is, 
however,  sometimes  the  seat  of  fatty  infiltration. 

The  dm-ation  of  acute  tuberculosis  in  the  child  is  seldom  prolonged. 
In  infants  it  may  last  six  weeks  or  two  months  ;  in  older  children  some- 
what longer.  The  length  of  the  illness  principally  depends  upon  the  du- 
ration of  the  early  stage,  for  when  local  symptoms  occur  showing  im- 
plication of  special  organs,  the  disease  usually  runs  rapidly  to  its 
close. 

Diagnosis. — The  disease  with  which  acute  tuberculosis  is  most  apt  to 
be  confounded  is  typhoid  fever.  This  is  especially  the  case  when  the  tu- 
bercular affection  begins  abruptly  with  high  fever,  headache,  and  bleeding 
fi'om  the  nose.  A  diagnosis  is  then  impossible  at  the  first ;  indeed  it  is 
often  only  by  the  after-course  of  the  ilhiess,  and  the  prolongation  of  the 
pyrexia  beyond  the  time  when  in  typhoid  fever  a  fall  of  temperature  may 
be  looked  for,  that  suspicions  are  excited  of  the  real  nature  of  the  disease. 
The  diagnosis  between  an  ordinary  case  of  acute  tuberculosis  and  tyjjhoid 
fever  is  given  elsewhere  (see  page  83). 

Sometimes  cases  of  acute  gastric  catarrh  may  j)resent  considerable  re- 
semblance to  acute  tuberculosis  in  its  early  stage.  Not  long  ago  I  was 
consulted  about  a  boy,  seven  or  eight  years  of  age,  who  had  at  one  time 
suffered  to  my  own  knowledge  fi'om  slight  consolidation  of  the  right  apex, 
the  consequence  of  an  attack  of  catarrhal  pneumonia.  The  boy  was  of 
scrofulous  type,  thin  and  pale.  He  was  said  to  have  been  losing  flesh  for 
some  time  and  to  have  had  a  poor  appetite.  For  more  than  a  week  his 
appetite  had  been  exceptionally  bad  ;  his  temperature  had  been  raised,  and 
he  had  had  a  hacking  cough.  I  saw  the  boy  at  5  p.m.,  with  Dr.  J.  N.  Miller, 
whose  patient  he  was.  The  boy's  temperature  was  then  100.2°.  He  was 
pale  with  no  flush  on  his  cheeks  ;  and  his  face  was  bright  and  lively  with- 
out any  sign  of  distress.  His  chest  was  everywhere  perfectly  normal, 
except  for  a  little  dry  rhonchus  about  the  back.  His  belly  was  not  dis- 
tended. There  was  no  enlargement  of  the  liver  or  spleen,  and  no  swollen 
mesenteric  glands  could  be  felt.  He  had  no  sore  throat.  The  tongue  was 
furred,  and  the  breath  had  a  faint  unpleasant  smell.  There  was  no  albu- 
men in  the  water,  nor  any  trace  of  oedema  of  the  legs.  The  spirits  of  the 
child  were  said  to  be  remarkably  good  ;  and  I  was  told  that  that  morning 
he  had  been  seen  attempting  the  acrobatic  feat  of  standing  on  his  head. 
This  latter  fact,  joined  with  the  bright  expression  of  the  boy's  face,  the 
signs  of  gastric  derangement,  and  the  absence  of  all  evidence  of  pulmonaiy 
mischief,  appeared  to  me  to  afford  sufficient  ground  for  excluding  tuber- 
culosis. I  accordingly  expressed  an  opinion  that  the  bo}^  was  suflering 
merely  from  a  subacute  attack  of  gastric  catarrh.  Shortly  afterwards  I 
heard  that  the  febrile  symptoms  quickly  disappeared. 

According  to  my  experience,  children  suffering  from  the  development 
of  tubercle  are  invariably  dull  and  spiritless,  and  usually  show  signs  of 
distress  in  the  face.     If  a  boy  jumps  about  and  plays  boisterously,  as  if  he 


ACUTE  TUBEECULOSIS — DIAGISTOSIS.  199 

were  well,  acute  tuberculosis  may  be  excluded  with  a  higb  degree  of  prob- 
ability. 

The  detection  of  acute  tuberculosis  depends  in  a  great  measure  upon 
the  absence  of  symptoms  capable  of  explaining  differently  the  serious  con- 
dition of  the  patient.  If  a  child  is  brought  with  a  history  of  fever  and 
wasting  of  some  weeks'  duration,  if  he  looks  ill,  with  a  distressed  haggard 
face,  and  if  a  careful  examination  of  the  whole  body  discovers  no  disease 
of  organs,  the  state  of  the  child  is  evidently  not  to  be  attributed  to  any 
local  cause.  In  such  a  case  the  diagnosis  will  lie  between  typhoid  fever 
and  tuberculosis,  and  if  from  the  duration  of  the  illness,  or  for  reasons 
given  elsewhere  (see  page  83),  typhoid  fever  can  be  excluded,  we  shall  be 
reduced  to  tuberculosis  as  the  only  other  probable  explanation  of  the 
child's  state.  In  a  badly  fed  infant  who  has  been  irregularly  feverish  from 
teething,  and  whose  nutrition  has  been  some  time  defective,  the  history  of 
wasting  and'  pyrexia  may  raise  suspicions  of  tuberculosis.  But  in  such  a 
case  the  child  will  not  look  haggard  and  pinched  like  one  suffering  from 
that  disease  ;  the  irregular  and  often  greatly  elevated  temperature  of  den- 
tition is  unlike  the  moderate  pyrexia  of  the  tubercular  affection,  and  will 
be  sufficiently  explained  by  inspection  of  the  gums.  Moreover,  the  history 
of  the  illness,  which  will  almost  certainly  include  several  attacks  of  diar- 
rhoea or  sickness,  and  the  account  of  the  child's  diet  will  furnish  an  amply 
sufficient  explanation  of  his  continued  indisposition.  In  an  infant  acute 
tuberculosis  is  almost  always  accompanied  by  oedema  of  the  legs.  At  this 
period  of  life  the  combination  of  wasting,  moderate  pyrexia,  and  oedema  of 
the  lower  limbs  is  a  very  suspicious  one.   . 

Even  when  the  case  is  first  seen  in  its  later  stage,  after  signs  of  local 
dis  "^ase  have  become  CAddent,  the  diagnosis  is  not  always  easy.  The  physi- 
cal signs  of  tuberculous  bronchitis  have  no  special  character  distinctive  of 
their  specific  origin,  and  they  must  be  read  in  the  light  afforded  by  the 
history  and  course  of  the  illness  in  order  that  they  may  be  rightly  inter- 
preted. In  tuberculous  bronchitis  the  temperature  is  higher  than  is  found 
in  an  uncomplicated  case  of  the  catarrhal  disease.  In  simple  capillary 
bronchitis  the  pulmonary  affection  is  seldom  accompanied  by  marked 
pyrexia,  and  the  mercury  rarely  rises  higher  than  101°  in  the  evening.  In 
tuberculous  bronchitis,  on  the  other  hand,  a  temperature  of  104°  is  not 
uncommon.  The  chief  point,  however,  is  the  occurrence  of  the  bronchial 
disorder  in  a  child  worn  and  weakened  by  illness  of  undefined  character 
and  accompanied  by  fever  and  wasting.  If  this  illness  have  succeeded 
after  a  variable  interval  to  an  attack  of  whooping-cough  or  measles,  the  fact 
alone  should  raise  a  suspicion  of  the  tuberculous  nature  of  the  pulmonary 
complaint.  So,  also,  if  broncho-pneumonia  supervene,  with  spots  of  local 
consolidation,  the  history  of  previous  ill  health  is  essential  to  a  right  un- 
derstanding of  the  nature  of  the  child's  complaint.  In  either  case  the 
onset  of  symptoms  pointing  to  intracranial  mischief  is  of  the  utmost 
value  in  confirming  our  suspicions  ;  and  if  convulsions  occur,  followed  by 
squinting,  ptosis,  unequal  pupils,  and  rigidity  of  the  joints,  the  tubercu- 
lous natiu-e  of  the  disease  may  be  considered  to  be  established  (see  also 
page  440). 

In  tuberculosis  of  the  bladder  the  child's  distress  is  usually  attributed 
to  the  presence  of  a  vesical  calculus.  There  is,  however,  one  diagnostic 
point  of  considerable  importance.  The  irritation  excited  in  children  by  a 
stone  in  the  bladder  is  rarely  a  cause  of  noticeable  pyrexia,  while,  when  the 
symptoms  are  dvie  to  vesical  tuberculosis,  the  evening  temperature  may 
reach  102°  or  hicfher.     Moreover,  digital  examination  after  the  manner  re- 


200  DISEASE   !>}"   CHILDEElSr. 

commended  by  Yolkmann,  abeadv  refeiTed  to,  will  sometimes  detect  a 
tuberculous  nodule  in  the  fundus  of  tbe  bladder. 

Prognosis. — The  prospects  of  a  child  in  whom  acute  tuberculosis  has 
revealed  itself  unmistakably  are  yery  desperate.  In  the  earlier  stage  of  the 
disease,  while  any  uncertainty  exists  as  to  the  nature  of  the  illness,  we  can 
still  hope  ;  but  when  a  secondary  bronchitis  or  catarrhal  pneumonia  arises, 
or  signs  of  inti-acranial  mischief  ai-e  noticed,  death  may  be  considered  cer- 
tain. Attacks  of  gastric  catarrh  in  children  -nith  tuberculous  and  scrofu- 
lous tendencies  are  almost  invariably  accompanied  by  fever.  If  the  attack 
is  protracted  or  rapidly  recurs,  an  intermittent  pyrexia  may  continue  for 
some  weeks,  and  on  recoveiy  the  child  may  be  thought  to  have  passed 
through  an  attack  of  tuberculosis.  Probably  most  instances  of  alleged 
recovery  from  acute  tuberculosis  are  cases  of  this  kind. 

Treatment. — '^^^len  a  case  of  acute  tuberculosis  has  occiu'red  amongst 
the  younger  members  of  a  family  very  special  measures  should  be  taken 
to  preserve  the  health  of  those  who  remain.  They  should  sleep  in  well 
ventUated  rooms,  be  warmly  clothed,  and  be  taken  out  of  doors  regularly 
for  exercise.  Such  children  should,  if  possible,  live  much  in  the  country 
on  a  sandy  or  gravell}'  soil,  and  should  avoid  the  vitiated  air  of  towns. 
Their  diet  should  be  plain,  and  excess  of  sweets  and  fermentable  matter 
should  be  forbidden.  Children  with  tubercular  tendencies  should  not  be 
taught  too  early.  It  is  wise  to  postpone  regular  education  until  they 
reach  their  sixth  or  seventh  year  ;  and  every  care  shoidd  be  taken  that 
theii"  sensitive  brains  are  not  overtasked.  The  mother,  if  herself  of  frail 
constitution,  shoiold  be  forbidden  to  suckle  her  infant,  and  a  healthy 
wet-nui'se  should  be  provided.  Any  signs  of  indigestion  in  such  sub- 
jects should  be  promptly  treated,  and  the  utmost  vigilance  should  be 
exercised  to  maintain  the  nutritive  processes  of  the  body  at  a  healthy 
standard. 

All  catarrhs,  however  mild  they  may  be,  should  at  once  receive  atten- 
tion, and  the  pai'ents  should  be  warned  of  the  danger  of  treating  the  child 
as  if  he  were  well  before  all  signs  of  his  temporaiy  ailment  have  disap- 
peared. Acute  diseases,  especially  the  exanthemata,  have  pecuhar  dangers 
for  these  children  ;  and  during  the  period  of  convalescence  the  patients 
should  be  put  into  the  most  favoui-able  conditions  for  insuiing  complete 
recovery.  A  good  sea  ah'  should  be  always  advised  in  these  cases  as  soon 
as  the  child  is  well  enough  to  be  moved  fi-om  his  home. 

T\Tien  the  disease  declares  itself  no  di'ugs  appear  to  have  any  value  in 
ari'esting  its  coiu'se,  and  veiy  Httle  in  retarding  the  fatal  issue.  Some- 
thing may  be  done  by  treating  symptoms  and  putting  a  stop  to  enfeebling 
comphcations.  Thus  the  looseness  of  the  bowels,  which  is  often  an  early 
symptom  of  the  disease,  may  be  usually  controlled  by  a  powder  containing 
three  or  four  gTains  of  rhubarb  with  double  the  quantity  of  aromatic  chalk 
powder  eveiy  night ;  and  twice  a  day  a  draught  containing  dilute  sulphuiic 
acid  (TF[  iij.-v.),  with  tinct.  opii  (Tr[  j.-ij.),  and  a  few  drops  of  glycerine  in 
a  teaspoonful  of  water.  Sometimes  the  carbonate  of  bismuth  in  full  doses 
(gr.  X.-XX.)  may  be  substituted  with  advantage  for  the  rhubarb  in  the 
powder.  If  in  spite  of  these  remedies  the  looseness  still  continues,  gallic 
acid  (gr.  ij.-v.)  can  be  given  with  laudanum. 

It  is  xevj  difficult  to  reduce  the  pyrexia  in  acute  tuberculosis.  Large 
doses  of  quinine  have  no  more  than  a  temporary  eifect,  and  often  appear  to 
be  quite  useless  ;  sahcyhc  acid  and  its  compounds  have  httle  beneficial 
influence  ;  and  the  hypophospLites  have  not  in  my  hands  been  followed  by 
satisfactory  results.     The  hypophosphite  of  lime,   however,   although  it 


ACUTE  TUBEKCULOSIS — TREATMENT.  201 

does  not  reduce  tlie  heat,  is  useful  in  alleviating  the  various  forms  of 
catarrh  so  common  in  tuberculous  children,  and  often  has  a  sensible 
influence  in  improving  the  appetite,  and  sometimes,  temporarily,  the 
strength. 

Inflammatory  chest  affections  must  be  treated  upon  ordinary  principles. 
As  the  strength  of  the  child  dechnes,  stimulants  will  be  required,  and  the 
brandy -and-egg  mixture  must  be  resorted  to.  The  diet  should  be  such 
as  is  recommended  for  other  febrile  diseases. 


CHAPTER  m. 

ESTFANTILE    SYPHILIS. 

Syphilis  in  the  infant  is  generally  the  consequence  of  an  inherited 
taint.  It  then  presents  a  combination  of  the  so-called  secondary  and 
tertiary  stages  of  the  disease.  Sometimes,  however,  it  is  acquired,  and 
there  is  then  a  primary  lesion  as  in  the  adult.  In  this  latter  case  the 
symptoms  resemble  more  those  of  constitutional  sj^hilis  acquired  after 
puberty.  Still,  the  progress  of  the  disease  is  not  entii-ely  uninfluenced  by 
the  tender  age  of  the  patient,  for  in  after-childhood  we  can  often  discover 
many  symptoms  which  are  common  to  the  inherited  form  of  the  malady. 

Causation. — The  congenital  taint  may  be  derived  from  either  the 
father  or  the  mother ;  and  the  severity  of  the  transmitted  disease  is  in 
direct  proportion  to  the  shortness  of  the  time  which  has  elapsed  since  the 
appearance  of  constitutional  symptoms  in  the  parent. 

The  disease  may  originate  with  the  father.  In  this  case  much  discus- 
sion has  arisen  as  to  the  mode  in  which  the  mother  becomes  affected,  or 
as  to  whether  she  becomes  affected  at  aU.  In  cases  where  there  is  no  evi- 
dence of  direct  contagion,  it  has  been  held  by  some  obsers^ers  that  the 
mother  may  be  infected  by  tainted  spermatic  fluid,  although  no  primary 
lesion  is  produced.  Others  believe  'that  the  infection  only  takes  place  at 
the  time  when  conception  occurs  ;  others,  again,  deny  that  even  in  this 
case  can  infection  be  conveyed  ;  while  a  fourth  class  insists  that  when  the 
mother  becomes  herseK  syphilitic  the  vu'us  is  introduced  only  indirectly, 
being  absorbed  into  her  system  from  the  tainted  embiyo.  This  discussion 
has,  no  doubt,  great  scientific  interest,  but  is  of  little  practical  value.  •  Of 
far  greater  importance  is  it  to  remember  that  a  man  may  beget  a  syphihtic 
child  long  after  constitutional  symptoms  have  ceased  to  appear  in  his  own 
person.  From  the  researches  of  Dr.  Kassowitz  it  appears  that  when  left 
untreated,  a  series  of  years — six,  eight,  ten,  or  even  more — may  elapse  be- 
fore a  man  is  relieved  from  the  obhgation  of  transmitting  the  taint  to  his 
offspring.  When  mercurial  treatment  is  adopted,  the  remedy  destroys  for 
a  time  the  power  of  the  virus,  and  the  parent  is  then  capable  of  begetting 
a  healthy  child.  But  this  immunity  from  transmitting  the  disease  is  not 
permanent.  In  some  cases  the  influence  of  treatment  becomes  exhausted 
after  a  longer  or  shorter  time,  and  the  poison  recovers  something  of  its 
former  virrdence. 

"With  regard  to  the  escape  of  a  mother  who  has  borne  a  syphditic  child, 
it  seems  certain  that  the  escape  must  be  incomplete,  for  she  acquires  a 
strange  immunity  from  further  infection.  Long  ago  Colles  laid  it  down 
as  a  canon  that  "  a  new-born  child  affected  with  inherited  syphilis,  even 
although  it  may  have  symptoms  in  the  mouth,  never  causes  ulceration  of 
the  breast  which  it  sucks,  if  it  be  the  mother  who  suckles  it,  although  contin- 
uing capable  of  infecting  a  strange  nurse."  This  law  holds  good  as  com- 
pletely now  as  when  Colles  wrote  in  1837  ;  and  it  is  difficult  to  understand 


IXFAjSTTILE   syphilis — CATTSATIOj^ — MORBID   ATf ATOMY.      203 

how  tlie  motlier  can  be  proof  against  the  poison  unless  she  be  herself  the 
subject  of  the  disease. 

Still,  there  is  no  question  of  the  apparent  immunity  of  many  women 
the  mothers  of  syphihtic  children.  Dr.  Kassowitz  has  brought  forward 
instances  to  prove  that  the  most  careful  examination,  combined  with  watch- 
ing extending  over  many  years,  may  fail  to  detect  signs  of  syphilis  in  women 
who  have  borne  diseased  children.  It  certainly  does  appear  possible  that, 
as  Mr.  Hutchinson  believes,  a  woman  may  have  a  form  of  disease  too  fee- 
ble to  give  rise  to  external  manifestations,  but  strong  enough  to  protect 
her  from  further  contamination.  Mx.  Berkeley  Hill  insists  that  in  ah  these 
cases  the  escape  of  the  mother  is  not  real.  He  believes,  too,  that  in  most 
cases  she  has  contracted  syphihs  in  the  usual  manner  by  direct  contagion, 
but  that  the  primary  sore  has  escaped  notice  through  examination  having 
been  delaj^ed  too  long  after  the  date  of  infection. 

The  mother  alone  may  be  diseased,  the  father  being  health}'.  In  this 
case  if  the  mother  have  contracted  the  disease  shortly  before  conception, 
and  exhibit  the  secondary  rash  during  her  period  of  gestation,  the  child 
probably  never  escapes.  If  four  or  more  years  have  elapsed  since  her  in- 
fection at  the  time  when  she  becomes  pregnant,  she  may  have  lost  her 
power  of  transmitting  the  disease  and  the  child  may  be  spared. 

If  the  mother  be  actually  pregnant  when  the  virus  first  enters  her  sys- 
tem, she  may  or  may  not  communicate  it  to  her  offspring.  Much  depends 
upon  the  period  of  gestation  at  which  infection  took  place.  The  more  ad- 
vanced the  disease  in  the  mother  before  her  confinement,  the  more  hkely  is 
the  infant  to  inherit  the  taint ;  and  if  a  secondary  rash  have  appeared  upon 
the  mother's  body  before  the  end  of  her  pregnancy,  the  child  usually  suffers 
severely  from  the  transmitted  disease.  In  the  initial  stage  of  the  malady 
the  power  of  the  mother  to  impart  the  taint  is  less  certain  ;  and  it  is  im- 
probable that  the  foetus  can  be  infected  if  the  parent  have  not  herself 
suffered  from  constitutional  symptoms.  Therefore,  if  she  only  contract  the 
disease  towards  the  close  of  her  pregnancy,  the  infant  has  a  fair  chance  of 
escape.  There  is  no  evidence  to  show  that  the  disease  contracted  by  the 
mother  after  the  eighth  month  of  her  pregnancy  can  be  communicated  to 
the  foetus  in  her  womb. 

The  iufluence  of  mercurial  treatment  in  destroying  the  transmissive 
power  is  very  decided.  If  a  woman  who  has  borne  a  dead  or  diseased 
child  be  properly  treated  before  or  during  her  next  pregnancy,  the  infant 
borne  after  treatment  wiU  be  either  perfectly  healthy  or  will  suffer  very 
shghtly  from  the  inherited  taint.  Still,  as  in  the  case  of  syphihs  in  the 
father,  the  counteracting  power  of  the  remedy  is  apt  to  be  diminished  by 
time. 

When  a  healthy  infant  acquires  the  disease  after  bu'th,  it  is  usually  dwc- 
ing  lactation,  the  nipple  of  the  mother  or  nui'se  having  become  infected 
by  the  mouth  of  another  child  who  suffers  from  the  disease.  It  is  doubt- 
ful if  the  milk  alone  of  a  syphilitic  woman  is  capable  of  communicating  the 
complaint.  Again,  accidental  contact  with  specific  purulent  discharges, 
whether  from  a  primary  sore  or  a  secondary  lesion,  may  unpart  the  disease. 
In  either  case  the  sore  produced  in  the  child  is  a  primary  one.  Another 
method  by  which  the  syphilitic  poison  may  be  conveyed  to  a  healthy  child 
is  by  vaccination.  The  possibility  of  such  communication  was  long  denied  ; 
but  many  weU-authenticated  cases  in  which  this  deplorable  accident  has 
occurred  have  now  been  published,  and  the  evidence  in  its  favour  is  com- 
plete. 

Morbid  Anatomy. — Infantile  syphilis,  hke  the  other  diathetic  diseases 


204  DISEASE   IN   CHILDREN-. 

of  cliildbood,  may  affect  ihe  tissues  very  widely.  The  pathological  charac- 
ters may  be  divided  into  three  classes,  according  as  to  whether  the  part  affect- 
ed is  a  mucous  membrane,  a  sohd  organ,  or  a  part  of  the  bony  frame- work. 

The  mucous  membrane  may  be  the  seat  of  catarrh,  of  mucous  patches, 
or  of  ulcers.  All  these  may  be  seen  on  the  inside  of  the  cheeks  and  lips, 
the  fauces,  and  sometimes  the  small  intestine  ;  also  upon  the  laiynx,  the 
trachea,  and  even  the  bronchi. 

The  inside  of  the  mouth  is  a  common  seat  for  erosions  and  mucous 
patches.  They  do  not  s^^read  down  the  gullet,  according  to  Dr.  John 
Mackenzie  ;  nor  are  they  to  be  seen  on  the  ^Dosterior  wall  of  the  pharynx. 
In  rare  instances  syphilitic  ulceration  is  found  in  the  small  intestine.  I 
once  saw  a  httle  boy — four  years  of  age — the  subject  of  obstinate  diar- 
rhoea, in  whom  the  evacuations  had  all  the  characters  usually  found  in  cases 
of  ulcei'ation  of  the  bowels.  His  father  had  had  syj^hihs,  and  his  mother 
in  her  next  confuiement  gave  birth  to  a  distinctly  syphilitic  child,  and  had 
afterwards  several  miscarriages.  The  case  resisted  all  ordinary  remedies, 
but  was  eventually  cured  by  the  continued  apphcation  of  a  mercurial  oint- 
ment to  the  abdomen. 

Mucous  patches  and  ulcers  may  be  seen  on  the  glottis  and  epiglottis. 
The  vocal  cords  may  be  destroyed  by  ulceration  or  may  be  the  seat  of 
warty  growths.  A  case  is  elsewhere  related  (see  page  417)  in  which  ob- 
struction of  the  laiynx  by  warty  gTowths  occuiTed  in  a  child  who  had  a 
past  sy]3hilitic  history,  but^in  whom  no  other  constitutional  lesion  could 
be  discovered.  Sometimes  great  thickening  is  noticed  in  the  mucous 
membrane  of  the  glottis.  Thus,  in  a  case  reported  by  ErCss — a  syphihtic 
child  aged  thi*ee  and  a  half  years — a  laryngoscopic  examination  showed 
that  the  epiglottis  was  thickened  to  three  or  four  times  its  natural  size  ; 
the  ary-epiglottidean  cords  were  thickened  and  jDale  red  ;  the  left  vocal 
cord  was  more  than  twice  as  thick  as  the  right,  and  bulged  out  at  its  edge 
towards  its  fellow.  The  symptoms  were  aphonia,  and  frequent  convulsive 
fits  of  coughing  with  suffocative  attacks.  The  child  was  treated  with  mer- 
curial inunctions,  and  was  well  in  two  months  and  a  half.  According  to 
Dr.  T.  Barlow,  the  larynx,  even  after  recovery,  is  left  very  sensitive  and 
susceptible  to  ti'esh  catarrh.  The  mucous  membrane  of  the  trachea  and 
bronchi  may  be  affected  in  a  similar  way.  There  may  be  catarrh,  or  mu- 
cous patches,  or  shallow  ulcers  ;  but  these  lesions  are  less  common  here 
than  at  the  upper  part  of  the  respu'atory  jjassage.  In  rare  cases  the  ul- 
ceration may  be  extensive.  Thus,  Woronichin  found  in  a  child  of  fourteen 
months  old  ulceration  of  the  lower  j)art  of  the  trachea,  and  a  similar  lesion 
of  the  right  bronchus  which  extended  as  far  downwards  as  the  next  di- 
vision of  the  air-tube. 

In  solid  organs  sj^ohilitic  lesions  assume  the  form  of  fibroid  growths, 
which  may  be  either  diffused  or  circumscribed.  Whatever  organ  be  af- 
fected, the  nature  of  the  lesion  is  the  same.  There  is  hyj^erplasia  of  the 
connective  tissue  of  the  part.  This  grows,  thickens,  and  finally  contracts, 
so  that  the  proper  parenchyma  of  the  organ  is  obhterated  and  replaced  by 
a  solid  fibroid  material.  When  the  lesion  is  circumscribed  it  is  called 
"  gumma."  This  has  essentiaUy  the  same  structure  as  the  diffused  foiTQ, 
but  tends  to  soften  in  the  centre  by  a  process  of  fatty  degeneration. 

Diffi;sed  fibroid  change  is  seen  in  the  lungs,  liver,  spleen,  and  pancreas. 
Gummata  have  been  found  in  the  same  organs  ;  also  in  the  heart  and  sub- 
cutaneous tissue.  Occasionally  they  are  found  also  in  the  tongue  and  soft 
palate,  but  not  in  infants.  This  is  a  later  symptom  and  seldom  occui's  be- 
fore the  end  of  the  sixth  year. 


INFANTILE   SYPHILIS — MOEBID   ANATOMY.  205 

In  a  lung  the  seat  of  diffused  fibroid  change,  the  part  is  solid  and  gray 
in  colour,  with  a  smooth  sliining  section  traversed  by  fine  fibrous  lines.  It 
is  very  dense  and  tough.  Under  the  microscope  the  alveolar  walls  are  seen 
to  be  infiltrated  with  round  cells,  sjDindle  cells,  and  fibrous  tissue.  The 
round  and  spindle  cells  develop  into  fibrous  tissue,  which  thickens  the 
septa  and  compresses  the  alveoli.  There  is  also  free  production  *of  new 
vessels,  so  that  the  new  growth  is  very  vascular.  The  area  of  lung  thus 
affected  varies.  Usually  the  disease  extends  over  a  part  of  a  lobe,  or  even 
a  whole  lobe.  Besides  the  diflused  form,  gummata  are  seen  sometimes  in 
the  lungs.  These  are  rounded  well-defined  masses,  few  in  number,  usuaUy 
of  the  size  of  a  nut,  and  yellowish-white  or  gray  in  colour.  They  are  firm 
at  the  circumference,  but  get  softer  in  the  centre,  and  the  interior  may  be 
reduced  by  fatty  degeneration  to  a  puriform  matter.  Microscopic  ex- 
amication  shows  the  alveolar  walls  to  be  infiltrated  at  the  circumference 
of  the  tumour  with  nucleated  cells,  while  nearer  the  centre  round  or  oval 
cells  are  seen  in  a  finely  reticulated  tissue.  These  two  forms  of  the  same 
lesion  are  seldom  seen,  except  in  dead-born  or  very  young  infants. 

The  liver  may  be  affected,  and,  according  to  Dr.  Parrot,  is  most  fre- 
quently found  diseased  in  infants  who  die  six  weeks  after  birth.  The  or- 
gan is  enlarged  and  hardened,  and  may  be  the  seat  of  a  sclerosis,  diffused, 
as  in  the  lungs,  or,  more  rarely,  of  the  circumscribed  form.  According  tc 
Giibler,  who  first  drew  attention  to  this  condition,  the  organ  in  the  dif- 
fused fibroid  change  is  hypertrophied,  globular,  hard,  and  elastic,  and  its 
edges  are  rounder  than  in  health.  It  creaks  on  section,  and  the  cut  sur- 
face is  pinkish-white  or  yellow,  and  shows  layers  of  small,  white,  opaque 
grains  on  a  yeUomsh  uniform  ground.  The  capillary  vessels  are  obliter- 
ated, and  the  calibre  of  the  larger  vessels  is  increased.  These  changes  are 
due  to  the  development  of  new  fibro-plastic  tissue  which  compresses  the 
hepatic  cells,  obliterates  the  vessels,  and  checks  or  prevents  secretion  of 
bile.  Gummata  may  be  combined  with  the  preceding,  and  are  seen  as 
circumscribed  nodules  embedded  in  healthy  tissue.  The  masses  are  bright 
yellow,  and  present  under  the  microscope  the  usual  round  or  oval  cells. 
There  is  commonly  more  or  less  softening  in  the  centre,  while  at  the  cir- 
cumference the  normal  hepatic  cells,  between  which  the  infiltration  is  ad- 
vancing, become  hypertrophied. 

The  spleen  is  often  enlarged,  and,  according  to  Dr.  Gee,  if  the  enlarge- 
ment is  great  the  child  will  probably  die.  Dr.  Gee  considers  the  degree 
of  enlargement  to  be  an  index  of  the  severity  of  the  cachexia.  If  the  child 
improves  the  size  of  the  spleen  does  not  diminish  as  the  other  symptoms 
disajDpear,  but  continues  unaltered — often  for  years.  In  the  spleen,  as  in 
the  other  solid  organs,  the  disease  consists  principally  of  a  diffused  inter- 
stitial hyperplasia. 

The  heart  and  lungs  may  be  also  affected.  Gummata  have  been  found 
in  the  former  organ,  and  Dr.  Coupland  has  described  a  specimen  in  which 
the  muscular  walls  were  thickened  and  hardened,  and  showed  under  the 
microscope  an  almost  universal  infiltration  of  small  round  cells  amongst 
the  muscular  fibres.  In  the  same  case  the  kidneys,  although  normal  to 
the  eye,  were  seen  to  be  undergoing  similar  changes,  and  their  substance 
was  unnaturally  firm. 

The  thymus  gland  is  seldom  diseased.  Sometimes  collections  of  mat- 
ter are  found  scattered  through  its  interior,  but  it  is  not  clear  that  these 
are  the  consequence  of  the  syphilitic  taint. 

The  suprarenal  bodies  are  said  by  Virchow  to  be  frequently  the  seat 
of  a  fatty  degeneration.     Hiiber  has  described  a  condition  in  which  these 


206  DISEASE  IN   CHILDEEN. 

bodies  are  large,  grayish  on  the  outside,  translucent,  and  thick,  with  nu- 
merous white,  irregular  spots  dispersed  through  their  substance. 

The  bones  are  often  the  seat  of  profound  structural  disease.  Our 
knowledge  of  the  bone  disease  which  occurs  as  a  consequence  of  inherited 
syphilis  is  only  of  recent  origin.  Dr.  G.  Wegner  was  the  first  to  describe 
these  lesions,  and  attribute  them  to  their  true  cause,  in  1870.  More  re- 
cently Drs.  Parrot  and  Cornil  have  laboured  at  the  same  subject.  Dr. 
Taylor,  of  New  York,  who  has  collected  many  cases  of  his  own  and  analysed 
those  of  others,  gives  a  graphic  account  of  these  affections  in  his  well- 
known  volume. 

Disease  of  the  osseous  system  is  a  far  from  uncommon  lesion.  Accord- 
ing to  Dr.  Abehn,  of  Stockholm,  it  is  found  in  ten  per  cent,  of  the  cases. 
The  bones  especially  affected  are  the  long  bones  of  the  limbs  ;  next  come 
the  bones  of  the  skull,  the  ribs,  the  scapulae,  and  the  ihac  bones.  In  the 
long  bones  there  are  two  chief  varieties.  One  begins  with  the  periosteum 
— periosteogenesis:  the  other  is  not  connected  with  the  periosteum,  but 
is  confined  to  the  ossifjdng  hne  of  the  diaphysis — osteochondritis, 

Periosteogenesis  begins  as  a  periostitis.  Parrot  divides  it  into  two 
forms  :  the  osteoid  and  the  spongioid  or  rachitic.  The  former  may  occur 
from  the  earliest  period  of  life  ;  the  latter  is  rarely  seen  in  infants  of  less 
than  six  months  old. 

In  the  osteoid  form  we  find  one  or  more  layers  of  a  new  growth  which 
is  composed  of  interlacing  trabeculae  lying  perpendicularly  to  the  axis  of 
the  shaft.  The  periosteum  is  thickened  and  adherent  to  the  growth,  and 
the  latter  has  a  chalky  appearance  from  copious  infiltration  with  calcareous 
salts.  Consequently  it  is  whiter  and  more  friable  than  the  bone  beneath, 
and  the  line  of  junction  is  well  defined.  The  osteoid  material  is  found  on 
the  shafts  of  the  long  bones  and  on  the  cranial  bones.  In  the  latter  situ- 
ation it  may  reach  an  inch  or  more  in  thickness.  By  the  microscope  we 
find  differences  in  structure  from  true  bone.  There  are  no  bone  cor- 
puscles regularly  disposed  round  the  Haversian  canals  ;  instead,  corpuscles 
■ — three-sided  or  polygonal,  resembling  the  stellate  corpuscles  of  connec- 
tive tissue — anastomose  by  their  x3rocesses  with  the  cells  of  the  periosteum, 
with  corpuscles  in  the  mediillary  spaces,  and  with  one  another. 

In  the  s^Dongioid  form,  which  is  not  seen  in  children  under  six  months 
of  age,  a  new  fibroid  tissue,  pearly  gray  or  yellowish  in  colour,  is  formed 
between  the  periosteum  and  the  bone.  It  is  more  vascular  than  normal 
osseous  tissue. 

The  osteoid  and  spongy  growths  are  often  combined.  If  the  new  ma- 
terial consist  of  several  layers,  some  may  be  more  trabecular,  others  more 
spongy  in  structure — the  chalky  layer  being  nearer  the  bone,  the  fibroid 
immediately  beneath  the  periosteum.  While  this  process  is  going  on 
around  it,  the  shaft  of  the  bone  may  be  unaltered.  This  is  usually  the 
case  in  very  young  babies.  In  older  children  the  calcareous  matter  of  the 
shaft  may  become  absorbed,  and  the  tissue  be  separated  into  layers  by 
the  formation  of  furrows  filled  with  medulla.  The  bone  as  a  consequence 
becomes  light,  porous,  and  brittle.  The  ends  of  the  bones  are  thickened, 
partly  by  the  periosteogenetic  growth,  partly  by  granulations  thrown  out 
from  the  spongioid  tissue  of  the  shaft. 

Osteochondritis  appears  to  consist  in  a  suppurative  ostitis  affecting  the 
epiphyseal  end  of  the  bone.  The  layer  of  cartilage  preparing  for  ossifica- 
tion becomes  thickened  to  three  or  four  times  its  natural  width,  and  gets 
transparent  and  soft.  This  increase  in  width  is  due  to  excessive  prolifera- 
tion of  the  cartilage  cells,  which  assume  much  the  shape  and  size  of  the 


INFANTILE   SYPHILIS — MOEBID   ANATOMY.  207 

round  granulation  cells  of  syphilitic  gummata.  At  the  same  time  the 
intercellular  substance  is  diminished.  The  cartilage  which  is  actually 
undergoing  ossification  is  thickened,  and  shows  on  section  a  broad  wavy 
line.  By  the  microscope  the  osteoblasts  are  found  to  be  replaced  more  or 
less  completely  by  small  granulation  cells  or  spindle-shaped  elements. 
After  a  time  destructive  changes  set  in  in  the  bony  tissue.  Dr.  Parrot  de- 
scribes a  "  gelatiniform  softening,"  in  which  the  bone  is  replaced  by  a  soft, 
rather  transparent  material  of  a  yellowish  or  brownish  colour.  After 
death,  when  the  bone  is  dry,  a  cavity  is  left.  The  cancellous  structure  is 
also  infiltrated  with  purulent  watery  fluid,  so  that  the  lamellse  disappear 
and  leave  a  fibro-Vascular  network  filled  with  the  same  fluid.  According 
to  Wegner,  a  characteristic  feature  of  this  osseous  disease  is  the  protru- 
sion of  bundles  of  fibrous  tissue  along  the  course  of  the  blood-vessels. 
These  bundles  pass  through  the  cartilage,  the  calcifying  layer,  and  the 
processes  of  sj)ongy  bone,  and  penetrate  deeply  into  the  cancellous  tissue 
of  the  shaft. 

As  a  consequence  of  this  lesion  the  epiphyses  with  the  ossifying  layer 
may  separate  from  the  shaft  of  the  bone.  Suppuration  is  then  set  up,  an 
abscess  forms,  and  the  pus  escapes  into  the  surrounding  tissue  by  penetrat- 
ing the  periosteum.  The  joint  itself  is  not  involved  as  a  rule  ;  but  Dr. 
Lees  has  reported  a  case  in  which  the  left  elbow-joint  and  both  knee-joints 
became  filled  with  pus. 

Periosteogenesis  is  more  common  than  osteochondritis.  It  attacks  par- 
ticularly the  humerus  and  the  tibia  ;  and  gives  rise  to  symptoms,  recog- 
nised during  life,  which  will  be  afterwards  described. 

An  osseous  lesion,  due  probably  to  changes  similar  in  character  to 
those  described  above,  and  called  dactylitis,  may  attack  the  bones  of  the 
hands  and  feet.  Dr.  Taylor,  of  New  York,  has  contributed  much  to  our 
knowledge  of  this  affection.  According  to  this  author,  the  disease  begins 
either  in  the  fibrous  tissue  surrounding  a  joint  or  in  the  periosteum.  In 
the  first  form  slight  enlargement  is  seen  of  one  or  more  toes  or  fingers — 
either  of  the  whole  length,  as  occurs  in  the  toes,  or  of  one  or  more  pha- 
langes, as  is  seen  in  the  case  of  the  fingers.  The  process  is  slow  and  is 
accompanied  by  little  or  no  pain,  although  the  swelling  interferes  with  the 
play  of  the  joint.  The  second  form  is  most  frequently  seen  in  the  fingers. 
One  or  more  of  the  phalanges  becomes  evenly  rounded  or  fusiform. 
When  the  first  phalanx  is  attacked,  it  usually  assumes  the  shape  of  an 
acorn.  The  metacarpal  and  metatarsal  bones  may  be  also  affected  in  the 
same  way.  In  all  cases,  as  a  rule,  the  tendency  is  to  resolution.  Still, 
sometimes,  if  the  enlargement  is  great,  the  j)art  is  exposed  to  accidental 
injury.  The  skin  then  becomes  swollen,  red,  and  tense  ;  ulcerates  or  is 
incised,  and  discharges  a  soft,  cheesy  detritus  mixed  with  pus.  Limited 
necrosis  may  follow  and  lead  to  shortening  of  the  finger.  Dactylitis  is 
usually  seen  in  very  young  children,  but  it  may  be  a  later  symptom.  The 
number  of  fingers  affected  varies.  Dr.  Taylor  mentions  a  case  in  which 
all  the  phalanges  of  both  hands  were  involved. 

The  bones  of  the  skull  may  be  affected  by  the  two  forms  of  disease 
which  attack  the  long  bones.  Gelatiniform  softening  is  comparatively 
rare,  but  is  sometimes  found  in  very  young  infants.  It  begins  beneath  the 
pericranium  but  does  not  penetrate  deeply  into  the  bone,  so  that  it  rarely 
reaches  the  dura  mater.  After  death  the  bone  has  a  Avorm-eaten  appear- 
ance. This  form  cannot  be  diagnosed  during  life.  The  osteoid  growths 
are  only  found  in  older  children.  At  first  they  always  occupy  the  same 
situation,  viz.,  the  frontal  and  parietal  bones  surrounding  the  anterior  fon- 


208  DISEASE  IJ!^   CHILDREN. 

tanelle.  Sometimes  they  are  also  seen  in  the  temporal  bones,  but  are 
never  found,  unless  the  disease  be  exceptionally  severe,  in  the  orbital 
plates  or  the  occipital  bone.  As  they  grow  they  produce  a  very  character- 
istic deformity  of  the  skull.  The  fontanelle  comes  to  be  surrounded  by 
four  elevations,  which  are  separated  by  two  furrows  intersecting  one  another 
in  the  form  of  a  cross — the  one  transverse,  the  other  antero-posterior. 
These  osteophytes  are  usually  spongy  and  porous,  but  they  may  become 
hard  and  smooth  like  normal  bone  tissue.  They  sometimes  reach  an  inch 
and  a  quarter  m  thickness. 

In  addition  to  the  above  purely  syphilitic  changes,  local  thinning  of  the 
bone,  called  cranio-tabes,  is  often  found.  This  condition,  which  is  a  thin- 
ning or  even  j^erforation  in  certain  spots  of  the  cranial  bones,  was  until 
lately  considered  to  be  exclusively  a  symptom  of  rickets.  It  is  due  to  di- 
rect pressure  upon  the  bones  of  the  skull  by  the  brain  within  and  the 
pillow  without,  and  is  found  especially  in  the  occipital  bone.  It  may  be 
present  in  rickets  where  no  trace  of  syphilis  can  be  discovered,  but  is  most 
common  in  cases  where  there  is  a  distinct  syphilitic  taint.' 

It  is  difficult  to  say  with  certainty  at  what  age  a  child  becomes  liable  to 
syphilitic  disease  of  bone.  Gelatiniform  softening  and  osteochondritis 
generally  occur  earl}',  beginning  before  the  sixth  month,  and  it  is  probable 
that  they  may  even  be  present  in  intra-uterine  life.  Dr.  Taylor  has  most 
frequently  seen  osteochondritis  about  six  weeks  after  birth.  The  changes 
in  the  cranial  bones  seem  to  be  later  symptoms,  and  to  occur  most  com- 
monly after  the  second  year.  In  some  cases  reported  by  Drs.  Barlow  and 
Lees  the  ages  of  the  children  were  between  two  and  three  years.  Bone 
changes  usually  occur  in  the  most  severe  cases,  although  it  is  said  that 
they  are  sometimes  the  only  symptom  of  the  disease.  If  the  patient  re- 
covers, all  traces  of  the  morbid  growth  may  disappear,  but  it  is  not  rare 
to  find  curvatures  or  twists  left  as  evidence  of  the  cachexia  which  has 
passed  away. 

Symptoms. — The  first  manifestation  of  the  constitutional  taint  may  oc- 
cur early  or  late,  according  to  the  degree  to  which  the  system  is  afifected  by 
the  virus.  When  the  s^'philitic  poison  is  very  active,  the  disease  may  first 
show  itself  during  intra-uterine  life.  The  foetus  then  dies  and  is  born  dead 
before  the  proper  time.  Syphilis  is  thus  a  common  cause  of  miscarriage  ; 
and  in  all  cases  where  premature  labour  is  found  to  have  occurred  repeat- 
edly, we  should  not  fail  to  make  inquiry  as  to  the  previous  health  of  the 
parents.  If  examination  of  the  aborted  foetus  be  made,  the  bones  and  in- 
ternal organs  exhibit  signs  of  being  profoundly  affected  by  the  syphihtic 
poison. 

In  a  less  active  state  of  the  \irus  the  child,  although  diseased,  may  be 
born  ahve.  He  is  then  much  emaciated  and  looks  shrivelled.  His  bocly  is 
covered  vdth  an  eruption  of  pemphigus  which  extends  even  to  the  palms  of 
the  hands  and  soles  of  the  feet.  He  snulfies  and  has  a  hoarse  cry.  If,  as 
generally  happens,  the  internal  organs  are  extensively  diseased,  the  child 
dies.  If  no  disease  of  the  internal  organs  be  present,  the  child  may  hnger 
for  a  longer  time,  but  he  generally  dies  in  the  end.  It  is  only  in  ver}'^  rare 
cases  that  he  struggles  on  and  eventually  recovers. 

Usually  when  a  syphilitic  child  is  born  alive,  he  has  at  first  a  healthy 

'  Out  of  one  hundred  cases  of  cranio-tabes  collected  by  Drs.  Barlow  and  Lees,  in 
forty-seven  there  was  satisfactory  proof  of  syphilis,  in  forty  there  was  more  or  less 
evidence  of  the  disease,  only  in  twelve  was  there  no  indication^of  syphilis  to  be  de- 
tected. 


INFANTILE    SYPHILIS— SYMPTOMS.  ,      209 

appearance.  After  a  time — often  between  two  and  six  weeks,  rarely  after 
three  months — the  first  signs  of  the  disease  appear.  Before  this,  however, 
the  child  in  many  cases  has  an  unhealthy  look,  although  it  is  difficult  to 
say  in  what  this  unhealthiness  consists.  There  is  often  great  restlessness  ; 
and  the  infant  may  sleejo  badly  at*  night,  sometimes  breaking  out  into 
paroxysms  of  violent  crying,  which  are  a  source  of  great  perplexity  and  dis- 
tress to  his  attendants.  It  seems  probable  that  this  symptom  is  due  to 
nocturnal  pains  in  the  bones,  such  as  often  affect  adults  before  the  outbreak 
of  constitutional  symptoms.  The  sleeplessness  soon  ceases  under  the  in- 
fluence of  specific  treatment.  Sometimes  the  outbreak  of  the  general  symp- 
toms is  determined  by  a  febrile  disease,  such  as  vaccination  or  one  of  the 
exanthemata.  Thus,  it  is  not  very  rare  to  see  the  rash  of  measles  subside 
leaving  the  syphilitic  eruption  in  its  place. 

Snuffling  is  one  of  the  earliest  symptoms.  It  should  always  be  inquired 
for,  as  Avlnle  the  child  is  breathing  through  the  mouth  it  is  not  noticed,  and 
the  mother  attributing  the  symptom  to  a  cold  may  not  think  it  deserving 
of  mention.  The  snuffling  is  most  evident  when  the  child  takes  the  breast, 
and  his  manner  of  doing  so  is  veiy  characteristic.  Each  breath  is  drawn 
with  difficulty  through  the  nostrils,  and  if  the  obstruction  is  great  respira- 
tion has  to  be  suspended  while  the  babe  sucks.  Consequently,  he  can  only 
draw  the  milk  by  short  snatches.  After  every  two  or  three  mouthfuls 
he  is  forced  to  desist,  and  can  be  seen  lying  with  the  nipple  in  his  half  open 
mouth  so  as  to  renew  his  supjDly  of  air  before  he  begins  again.  A  discharge 
from  the  nostrils  soon  appears.  This  is  at  first  watery,  but  soon  becomes 
thicker  and  forms  crusts  which  block  up  the  nasal  openings.  Little  ulcera- 
tions and  cracks  are  generally  seen  about  the  nostrils  and  upper  lip,  due 
either  to  mucous  j)atchesor  to  scalding  by  the  irritating  secretion  fi'om  the 
nose.  In  bad  cases  ulceration  of  the  Schneiderian  membrane  may  take 
place,  and  the  septum  is  sometimes  perforated.  Occasionally,  necrosis  of 
the  nasal  bones  follows,  and  fragments  of  the  bones  may  be  found  in  the 
dried  discharge.  The  bones  may  be  also  loosened  so  that  the  bridge  of  the 
nose  is  flattened  and  sinks  down. 

Another  early  symptom  is  the  rash.  This  appears,  as  a  rule,  shortly 
after  the  beginning  of  the  coryza.  It  is  seen  as  flattened,  slightl}^  elevated 
spots,  of  a  rusty  red  or  coppery  colour,  scattered  over  the  perinseum,  upon 
the  genitals,  and  around  the  anus.  Sometimes  it  begins  as  a  uniform,  dingy 
red  blush  covering  the  belly,  the  perinseum,  and  the  buttocks.  It  soon 
assumes  the  tint  of  the  lean  of  ham ;  its  edge  is  distinctly  circumscribed, 
and  at  the  circumference  isolated  spots  are  seen  of  the  same  colour.  The 
eruption  is  not  confined  to  the  lower  part  of  the  body.  It  is  often  seen  in 
the  folds  of  the  joints,  particularly  of  the  armpits,  along  the  sides  of  the^ 
neck,  and  over  the  chin.  Other  varieties  of  eruption  are  also  seen.  Ecthy- 
matous  and  tubercular  spots  are  not  uncommon,  and  mucous  patches  and 
ulcerations  are  constantly  present  on  the  skin.  The  ecthymatous  jDustules 
are  met  with  in-  the  more  weakly  children.  They  are  generally  covered  with 
a  thick  scab,  under  which  the  skin  may  ulcerate  into  deep,  sharply  cut  sores. 
Mucous  patches  lie  at  the  outlets  of  the  various  passages  opening  on  to  the 
surface  of  the  body,  and  in  other  places  where  the  skin  is  especially  delicate 
and  moist.  Thus  they  are  seen  around  the  anus,  and  in  a  girl  round  the 
vulva  ;  also  about  the  commissures  of  the  lips,  and  between  the  fingers  and 
toes.  They  are  round  or  oval  patches,  sKghtly  elevated.  The  surface  is  of 
a  grayish  colour  and  is  moistened  by  constant  secretion.  On  a  mucous 
membrane  they  quickly  become  converted  into  shallow  ulcers.  Ulcerations; 
and  cracks  invade  the  angles  of  the  mouth  and  alee  of  the  nose.  They  are 
14 


210  DISEASE   IK   CHILDEEIir. 

linear  and  leave  beliind  them  linear  cicatrices  when  they  heal.  The  skin 
itself  of  a  syphilitic  child  presents  a  very  characteristic  appearance.  In 
severe  cases  it  is  dry,  inelastic,  and  wrinkled  in  loose  folds.  The  complex- 
ion is  yellowish,  and  has  been  compared  to  weak  cafe-au-lait.  This  tint  is 
unequally  distributed,  being  most  mafrked  on  the  prorninent  parts,  as  the 
nose,  cheeks,  forehead  and  chin.  The  general  colour  of  the  skin  may  be 
muddy  ;  but  in  children  who  survive  it  generally  becomes  sing-ularly  blood- 
less, and  remains  pale  long  after  other  symptoms  have  disappeared. 

The  hair  and  eyebrows  sometimes  fall  out.  The  nails  may  also  be 
affected.  Inflammation  and  suppuration  occur  in  the  matrix,  so  that  the 
nutrition  of  the  nail  becomes  impaired  and  the  nail  gets  dry  and  is  cast 
off. 

The  cry  of  the  infant  is  a  noticeable  symptom.  It  is  hoarse  and  high- 
pitched  from  laryngeal  catarrh  or  extension  of  the  mucous  patches  to  the 
larynx.  Occasionally  the  hoarseness  is  accompanied  by  attacks  of  laryn- 
gismus stridulus.  In  almost  every  case  the  ossification  of  the  cranial 
bones  is  delayed  and  the  fontanelle  is  widely  open  ;  but  the  growth  and 
development  of  the  teeth  are  not  interfered  with,  for  the  teeth  are  cut 
early,  as  a  rule,  and  with  little  inconvenience  to  the  child.  Cranio-tabes 
is  present  in  the  large  majority  of  cases,  and  the  posterior  cervical  glands 
are  often  enlarged. 

The  bone  disease  presents  many  very  characteristic  symptoms.  The 
long  bones  should  be  examined  for  signs  of  enlargement,  especially  the 
humerus,  the  femur  and  tibia.  If  we  place  the  finger  and  thumb  on  the 
anterior  and  posterior  aspect  of  the  humerus  at  the  upper  part,  and  carry 
the  hand  downwards  along  the  shaft,  we  shall  often  notice  that  the  bone 
becomes  thickened  at  the  lower  end,  and  that  the  thickening  is  greatest 
at  the  point  of  junction  of  the  shaft  with  the  epiphysis.  In  the  tibia  the 
thickening  can  be  often  detected  on  the  inner  surface,  in  the  femur  on 
the  outer  and  inner  aspects  of  the  shaft.  Besides  these,  there  may  be 
beading  of  the  ribs  and  thickening  of  the  radius  and  ulna  above  the  wrist. 
The  osteophytes  on  the  cranial  bones  have  abeady  been  described. 

When  suppuration  takes  place  outside  the  joint,  especially  if  there  be 
fracture  of  the  neck  of  the  bone,  we  find  peculiar  symptoms.  The  child 
appears  as  if  paralyzed.  His  arms  lie  pronated  by  the  sides  of  his  body  ; 
his  legs  are  stretched  out  straight  in  the  cot ;  and  when  the  patient  is 
lifted  up,  they  hang  loose,  like  the  legs  of  a  doU,  swaying  from  side  to 
side.  Crepitation  can  sometimes  be  detected  between  the  shaft  and  the 
separated  epiphysis  ;  and  if  an  abscess  forms,  the  joint,  which  had  been 
tender  before,  becomes  bent  and  stiff  and  exquisitely  painful.  Parrot  has 
called  this  condition  "  syphilitic  pseudo-paralysis." 

A  form  of  real  paralysis  has  been  occasionally  seen  affecting  the  branches 
of  the  brachial  plexus,  and  causing  more  or  less  complete  loss  of  power  in 
the  arms.  In  two  cases,  described  by  Dr.  Henoch,  voluntary  movement 
was  almost  completely  lost  in  the  upper  extremities,  the  flexor  muscles  of 
the  fingers  alone  retaining  a  slight  trace  of  contractility.  There  were  other 
signs  of  sj^hilis,  and  the  paralysis  disappeared  under  the  influence  of 
mercury.  In  some  cases  a  peculiar  twisting  of  the  head  backwards  has 
been  noticed  when  the  child  is  placed  in  a  sitting  position. 

The  degree  to  which  the  child  is  affected  in  cases  of  inherited  syphiUs 
varies — partly  according  to  the  virulence  of  the  poison,  and  partly,  also, 
according  to  the  general  strength  of  the  infant.  In  rare  cases,  where  twins 
are  born  of  parents  suffering  from  this  disease,  the  two  children  may  be 
affected  very  unequally.     An  instance  of  this  came  under  my  own  notice. 


IjN^FANTILE    syphilis — SYMPTOMS — RELAPSES.  211 

The  children  were  three  months  old.  One  was  much  emaciated,  with  a 
shrivelled,  parchment-like  skin,  covered  with  pemphigus.  She  snuffled 
and  cried  hoarsely.  The  other  was  a  healthy-looking  child,  fat  and  stx-ong, 
with  a  good  complexion.  She  snuffled  and  showed  on  her  buttocks  signs 
of  recent  eruption  ;  but  was  never  thought  sufficiently  ill  to  require  medical 
advice. 

In  practice  we  see  every  degree  of  intensity  of  the  syphilitic  cachexia. 
In  one  case,  like  the  healthier  twin  just  mentioned,  the  infant  may  be 
plump  and  strong-looking,  with  few  symptoms  and  those  trifling  in  char- 
acter. In  another  the  child  is  wizened  and  wasted,  with  a  wrinkled, 
inelastic,  blotchy  skin.  He  is  peevish  and  restless,  crying  hoarsely  and 
whimpering  almost  constantly.  He  is  always  hungry,  for  the  state  of  his 
mouth  and  nasal  passages  offers  a  continual  impediment  to  his  drawing 
sufficient  nourishment  from  the  breast.  He  gets  weaker  and  weaker — 
partly  from  disease,  partly  fi-om  want  of  food.  Vomiting  and  diari-hoea 
perhaps  come  on,  and  his  miserable  little  life  soon  draws  to  a  close. 

When  the  infant  survives,  he  may  seem  quite  to  throw  oft*  all  traces  of 
his  illness,  and  grows  up  a  strong  healthy  child.  But  usually,  when  the 
symptoms  have  been  severe,  more  or  less  permanent  impression  is  pro- 
duced upon  the  system.  The  body  may  be  stunted  in  growth  ;  the  com- 
plexion earthy  or  unhealthy-looking  ;  the  hair  thin  and  brittle.  The  brain 
may  be  also  more  or  less  aftected,  and  epilepsy,  deficient  memory,  loss  of 
perceptive  power,  and  even  gradually  advancing  imbecility  are  enumerated 
as  consequences  of  the  disease. 

Relapnes. — In  rare  cases  the  symptoms  of  inherited  syphilis  are  said  to 
be  delayed  until  the  seventh,  ninth,  tenth  years,  or  even  later.  Most  of 
these  cases  are  no  doubt  instances  of  relapse  of  the  disease,  the  symptoms 
which  occurred  during  infancy  having  been  slight  and  transient.  The 
relapse  shows  itself  in  coppery  eruptions  on  the  skin  with  discharges  from 
the  nose,  ears,  etc.  The  skin  often  ulcerates,  and  the  nasal  bones  may  be 
destroyed  by  gummy  ostitis  so  that  the  bridge  of  the  nose  is  depressed. 
The  spongy  bones  and  hard  palate  may  ulcerate  away,  and  the  velum  and 
pillars  of  the  fauces  may  be  destroyed  so  as  to  throw  the  nose  and  mouth 
into  one  cavity.  The  eyes  may  be  affected  with  interstitial  keratitis  ;  the 
permanent  incisor  teeth  may  be  notched  and  dwarfed  ;  and  deafuess  may 
occur.  Deafness  is  the  consequence,  as  a  rule,  of  some  morbid  condition 
of  the  auditory  nerve.  It  is  seldom  accompanied  by  any  disease  of  the 
outer  or  middle  ear,  for  there  is  tinnitus,  and  the  patient  cannot  hear  a 
tuning-fork  placed  on  the  head.  It  is  most  common  between  the  fifth  and 
fifteenth  years,  and  can  seldom  be  improved  by  treatment. 

Epilepsy  has  been  mentioned  as  sometimes  occurring  in  syphihtic  chil- 
dren. It  is  usually  one  of  the  later  symptoms,  and  may  exist,  as  was  seen  in 
one  of  Dr.  Hughlings  Jackson's  cases,  Avithout  any  sign  of  organic  disease 
being  detected  in  the  brain  after  death.  Syphilitic  children  sometimes 
die  from  a  basic  meningitis  with  symptoms  similar  to  those  produced  by 
the  tubercular  form  of  the  disease.  They  may  also  succumb  to  a  cere- 
bral hemorrhage.  Dr.  Barlow  has  described  a  diffused  thickening  with 
opacity  of  the  arterial  coats  in  the  brain  as  sometimes  occurring  in  cases  of 
inherited  syphilis.  This  may  lead  to  thrombosis  of  vessels  or  rupture  of 
the  artery  with  fatal  haemorrhage. 

Lastly,  in  many  children  who  have  suffered  from  the  hereditary  form 
of  the  disease  we  may  find  amyloid  degeneration  of  internal  organs,  espe- 
cially of  the  liver,  the  spleen,  and  the  kidneys. 

Diagnosis. — When  the  symptoms  are  weU  marked  the  nature  of  the 


212  DISEASE   IX   CHILDEEJSr, 

disease  can  scarcely  be  mistekeu.  The  little,  old-looking  face,  -with  its 
dusky  comjDlexion,  its  fissured  lips  and  crusted  nostrils ;  the  snufiling  and 
hoarse  cry;  the  Avasted  body;  the  wiinkled  and  inelastic  skin;  the  ham- 
like redness  of  the  buttocks  and  perinseum —  all  these  symptoms  are  suf- 
ficiently characteristic.  Doubt  is  only  j)ermissible  Avhen  the  symptoms  are 
few  and  indistinct,  when  nutrition  is  unaffected  and  the  child  has  the 
ajopearance  of  fair  health.  In  such  cases  there  is  general  pallor  of  the  skin 
and  careful  examination  may  detect  a  few  coppery  spots  upon  the  body ; 
the  spleen  may  be  big,  and  we  may,  perhaps,  discover  some  enlargement 
of  the  lower  end  of  the  humerus  or  shaft  of  the  tibia.  Chronic  coryza  is 
sometimes  the  only  sign  of  the  disease.  Persistent  snuffling  in  babies  is 
commonly  of  syphilitic  origin.  If  it  be  combined  with  paUor  of  the  skin, 
specific  treatment  should  always  be  adoiDted,  especialh*  if  a  history  of  pre- 
vious miscarriages  can  be  obtained  from  the  mother. 

In  older  children  the  signs  of  past  disease  are  :  Flattened  bridge  of 
the  nose  from  long-continued  swelling  of  the  nasal  mucous  membrane 
when  the  bones  are  soft ;  marking  of  the  skin  by  little  pits  or  cicatrices 
from  former  ulceration,  especially  when  these  are  seated  about  the  angles 
of  the  mouth  ;  protuberance  in  the  middle  line  of  the  forehead  between 
the  frontal  eminences  from  specific  disease  of  the  frontal  bone  ;  enlarged 
spleen  and  marked  pallor  of  the  skin.  If  the  permanent  teeth  have  ajD- 
peared  the  incisors  should  always  be  examined  for  signs  of  the  charac- 
teristic malformations. 

In  cases  where  there  is  enlargement  of  the  ends  of  the  long  bones,  the 
diagnosis  from  rickets  has  to  be  made.  As  compared  with  inherited  syph- 
ihs  rickets  is  a  late  disease.  It  rarely  begins  before  the  ninth  month. 
The  lesions  of  syphilis  are  seen  early,  almost  always  before  the  sixth  month. 
Again,  the  bone  disease  in  s;s-philis  is  usually  eridence  of  a  profound  cachec- 
tic state.  It  is,  therefore,  in  most  cases  accompanied  by  other  and  un- 
mistakable symptoms  of  the  disease.  Moreover,  it  is  very  partial,  seldom 
affects  the  ribs,  and  is  not  symmetrical.  In  rickets  it  is  always  symmet- 
rical and  general  and  the  ribs  are  the  earhest  of  the  bones  to  be  affected. 
In  syphiHs  separation  of  the  end  of  the  bone  and  suppuration  around  the 
joint  are  not  uncommon.  In  rickets  these  lesions  are  never  seen.  Again, 
the  preliminary  symptoms  of  rickets  are  veiw  characteristic,  and  are  quite 
wanting  in  an  uncomplicated  case  of  inherited  syiohilis.  If,  in  any  case,  we 
find  that  the  bone  lesions  are  symmetrical  and  involve  the  ends  of  all  the 
long  bones,  if  there  is  an  absence  of  the  signs  of  inherited  syphilis  but 
a  history  of  the  symptoms  characteristic  of  the  early  stage  of  rickets,  and 
if  we  find  that  the  child's  dentition  is  backward,  and  that  at  ten  months  old 
he  is  sho'oing  no  disposition  to  "feel  his  feet" — we  shall  have  little  diffi- 
culty in  reaching  the  conclusion  that  the  case  is  one  of  rickets.  Still,  a 
mild  form  of  rickets  is  sometimes  engrafted  ujDon  a  syjDhihtic  constitution. 
Here  we  shall  find  symmetrical  and  general  enlargement  of  the  joints 
and  beading  of  the  ribs  combined  with  some  of  the  symptoms  of  present 
or  past  syphUitic  disease. 

Dactylitis  occurring  in  syphiHtic  children  must  be  distinguished  from 
the  necrosis  which  sometimes  attacks  strumous  subjects.  In  syphilis  the 
diseased  bone  is  evenly  enlarged,  and  no  inflammation  in  the  integuments 
occurs  unless  the  size  of  the  lump  exposes  it  to  accidental  injury.  In  the 
fibrous  form,  also,  the  swelHng  is  indolent  and  painless,  and  although  not 
quite  symmetrical,  as  in  the  osseous  variety,  is  distinguished  by  its  little 
tendency  to  end  in  suppuration  and  abscess.  In  strumous  necrosis  the 
bone  is  enlarged  rmevenly  and  generally  forms  a  lump  on  one  side.     This 


INFANTILE   SYPHILIS — PEOGNOSIS — TEEATMENT.  '      213 

lump  gets  bigger,  then  softens  and  suppurates,  adhesions  take  place  with 
the  integument,  and  finally  the  abscess  opens  and  discharges  cheesy  pus. 
On  exiDloring  the  abscess  bare  bone  is  found  at  the  bottom  of  the  cavity. 
In  all  these  cases  careful  inquiry'  should  be  made  for  history  or  sign  of 
syphilis  in  the  patient  or  other  children  of  the  family. 

Prognosis. — The  prognosis  is  serious  in  proportion  to  the  intensity  of 
the  cachexia.  The  general  condition  is,  therefore,  of  greater  importance 
iu  counting  the  chances  of  a  child's  recovery  than  the  severity  of  any  par- 
ticular symptom.  The  degree  of  intensity'  of  the  cachexia  may  be  esti- 
mated by  the  date  of  appearance  of  the  first  symptoms  of  the  disease,  and 
hj  the  extent  to  which  nutrition  is  interfered  with.  If  the  symptoms  ap- 
pear during  the  first  fortnight  and  the  child  progressively  wastes,  death 
may  be  anticipated  with  certainty.  All  intercurrent  derangements  which 
interfere  with  digestion  and  assimilation  of  food  sensibly  increase  the 
gravity  of  the  case.  Thus,  vomiting  and  diarrhoea,  which  rapidly  reduce 
the  strength  of  even  a  healthy  child,  must  be  looked  upon  as  very  serious 
complications. 

Disease  of  the  internal  organs  or  of  the  bones,  as  they  indicate  pro- 
found contamination  of  the  system,  make  the  case  a  very  anxious  one. 
Moreover,  the  interference  with  function  which  results  from  the  visceral 
disease  is  another  reason  for  forming  a  very  unfavourable  opinion  as  to  the 
result  of  the  illness. 

There  is  one  special  symptom  which  must  not  be  overlooked  in  forming 
a  prognosis.  This  is  the  condition  of  the  nasal  passages.  When  these  pas- 
sages are  occluded  from  swelling  and  incrustation  the  child  is  forced  to 
breathe  through  the  mouth.  Conseciuently,  he  can  take  but  little  nourish- 
ment, for  while  he  su«ks  he  cannot  breathe,  and  while  he  breathes  he  can- 
not suck.  The  amount  of  food  he  takes  is,  therefore,  veiy  inadequate  to 
the  wants  of  his  system,  and  he  is  in  danger  of  actual  starvation. 

If  the  disease  first  appears  several  months  after  birth,  and  if  the  child 
continues  plump,  and  does  not  sensibly  emaciate,  the  prognosis  is  favour- 
able even  although  particular  symptoms  may  be  severe. 

In  cases  of  relapse,  or  of  so-called  delayed  syphihs,  when  symptoms  ap- 
pear after  the  seventh  year,  much  depends  upon  the  early  recognition  of 
the  nature  of  the  malady.  Syphilitic  lesions  urgently  require  specific  treat- 
ment, and  the  so-called  tertiary  forms  of  the  disease  cannot  be  neglected 
without  serious  consequences.  Therefore,  to  look  upon  such  lesions  as 
scrofulous  in  their  nature,  to  be  treated  with  cod-liver  oil  and  tonics,  is  to 
commit  an  error  which  may  be  a  veiy  fatal  one  to  the  patient. 

Treatment. — In  every  case  where  a  woman  gives  bu'th  to  a  syphihtic 
child  the  nature  of  the  illness  should  be  explained  to  the  father,  so  that  by 
suitable  treatment  of  one  or  both  parents  their  future  children  may  be 
enabled  to  escape  the  disease.  Treatment  begun  during  pregnancy  is  often 
successful  in  preventing  the  taint  from  being  transmitted  to  the  foetus  ;  but 
it  should  be  begun  early  and,  if  it  can  bo  borne  for  so  long  a  time,  should 
be  continued  for  fully  three  months. 

In  the  child  it  is  important  to  attack  the  cachexia  at  the  earhest  possi- 
ble moment.  Therefore,  if  previous  children  have  been  syj)hilitic,  and  the 
parent  in  the  interval  have  undergone  no  treatment,  it  is  well  to  place  the 
new-born  child  at  once  under  the  influence  of  remedies,  even  although  he 
may  have  a  healthy  appearance  and  present  no  sj'mptoms  of  the  disease. 
Mercury  is  indispensable  to  the  successful  treatment  of  infantile  S3"phihs. 
It  may  be  either  given  internally  or  applied  externally.  In  bad  cases  it  is 
well  to  combine  internal  administration  with  external  apphcation,  so  as 


214  DISEASE   IX   CHILDREN. 

to  bring  the  system  as   quickly  as  possible  under  the  influence  of   the 
drug. 

Tbe  infant  may  be  given  one  gTain  of  gray  powder  twice  a  day,  either 
alone  or  combined  with  a  grain  of  carbonate  of  potash  or  a  few  grains  of 
prepared  chalk  to  prevent  iriitation  of  the  alimentary  canal.  After  a  week 
the  dose  can  be  increased  by  a  quarter  of  a  grain  every  three  or  four  daj-s 
until  two  or  thi-ee  grains  are  taken  tvdce  a  day.  If  the  powders  produce 
irritation  of  the  stomach,  they  can  be  omitted  for  a  day  or  two  until  the 
initation  has  subsided.  If  they  still  disagree,  it  is  better  to  change  the 
preparation  of  mercury.  In  this  case  perchloride  of  mercury  in  doses  of 
twenty  or  thu-ty  drops  of  the  ordinary  Pharmacopoeia  solution  (gi\  -^^  ^^ 
gr.  ^j^g)  can  be  given  in  a  teaspoonful  of  water  sweetened  with  glycerine 
two  or  three  times  a  day.  Children  take  this  salt  very  well,  and  it  will 
often  agree  when  the  gray  powder  excites  iiiitation  and  vomiting.  Calo- 
mel in  doses  of  one-twelfth  of  a  grain  is  sometimes  preferred,  but  it  is  a 
more  irritating  prejoaration  than  the  other. 

Externally,  mercury  can  be  employed  in  the  form  of  the  ordinary  mer- 
curial ointment.  The  most  convenient  method  of  using  this  salve  is  to 
smear  it  inside  the  flannel  band  which  covers  the  infant's  beUy.  T^lien 
this  is  done  gi-eat  cleanhness  must  be  observed.  The  whole  body  must  be 
washed  weU  with  soap  and  water  every  night  so  that  all  old  ointment  is 
removed  before  a  fresh  application  is  made.  Another  way  of  using  mercury 
externally  is  in  the  form  of  mercurial  baths.  Thu-ty  to  ninety  grains  of  the 
perchloride  may  be  dissolved  in  two  gallons  of  warm  water.  It  is  better  to 
begin  with  the'smaUer  cpantity  and  gTaduahy  to  increase  the  strength  of 
the  solution.  The  baths,  besides  their  eifect  upon  the  general  system,  have 
a  very  beneficial  local  influence  upon  the  cutaneous  lesions.  ^Tien  the 
cachexia  is  very  severe,  it  is  well  to  combine  external  with  internal  treat- 
ment ;  and  in  "^cases  where  there  is  great  u'ritabihty  of  the  stomach  or 
bowels,  we  may  be  forced  to  depend  exclusively  upon  the  cutaneous  ab- 
sorj)tion  of  the  remedy. 

If  a  mother  who  is  giving  suck  to  her  diseased  infant  be  herself  rmder- 
going  treatment,  it  may  be  unnecessary  in  addition  to  give  mercmy  to  the 
child.  Doubts  have  been  entertained  as  to  whether  mercury  is  reaUy  se- 
creted by  the  breast.  Cuherier  has  tested  the  milk  of  mercui'iahsed  moth- 
ers without  finding  evidence  of  the  drug  in  the  secretion.  StiU,  it  seems 
certain  that  an  appreciable  amount  of  the  remedy  must  reach  the  child  by 
this  means,  for  in  mild  cases  very  rapid  improvement  is  noticed  in  his 
symptoms  while  he  remains  at  the  breast.  In  cases  of  severity  I  am  disin- 
clined to  trust  to  the  child's  getting  a  sufficiency  of  the  di-ug  by  this  chan- 
nel, and  prefer  to  supplement  the  treatment  by  the  direct  apphcaiion  of 
mercurial  ointment  to  the  abdomen. 

"Willi p  specific  treatment  is  being  adopted,  we  must  do  our  best  to  im- 
prove the  general  nutrition  of  the  infant.  The  milk  in  syphilitic  mothers 
is  too  often  poor  and  wateiy,  and  ill-adapted  for  the  supply  of  sufficient 
nourishment  to  their  oifsprmg.  Therefore  if  the  child  wastes,  especially 
if,  by  frequently  requking  the  breast  and  ciying  peerishly  after  his  med, 
he  seem  to  be  ill-satisfied  by  the  milk  he  has  swallowed,  it  is  well  to  give 
alternate  meals  of  cow's  inilk  diluted  vidth  an  equal  quantity  of  barley-  ■ 
water,  and  containing  a  small  quantity  of  some  malted  food,  such  as 
Mellin's  Food  for  Infants.  If  the  child  have  a  difficulty  in  sucking,  on  ac^ 
count  of  the  condition  of  his  nasal  passages,  this  food  must  be  given  with 
a  syringe.  If  a  feeding-bottle  be  used,  care  must  be  taken  that  no  other 
child  be  allowed  to  suck  at  the  mouth-piece  used  for  the  diseased  infant, 


INFANTILE   SYPHILIS — TREATMENT.  215 

and  the  nurse  should  be  cautioned  not  to  put  the  teat  into  her  own 
mouth.  In  connection  "with  this  subject  it  may  be  well  to  remark  that  it 
is  a  duty  in  all  these  cases  to  warn  the  nurses  and  servants  in  immediate 
attendance  upon  the  child  of  the  danger  of  infection  from  mucous  patches 
and  other  discharging  sores  upon  the  patient's  body.  They  should  be  di- 
rected to  observe  great  cleanliness  ;  to  avoid  wiping  their  hands  upon  any 
cloth  or  towel  used  for  the  infant ;  and  if  they  have  a  finger  wounded  by 
any  accidental  cut  or  abrasion,  on  no  account  to  handle  the  child  unless 
the  part  is  properly  protected. 

The  infant  must  be  kept  perfectly  clean.  His  whole  body  should  be 
bathed  with  warm  water  twice  a  day  ;  and  if  mercurial  inunctions  are  being 
employed,  soap  should  be  used  for  the  evening  bath.  Care  must  be  taken 
to  dry  the  child  thoroughly  after  each  washing.  Fresh  air  is  of  the  utmost 
importance,  and  if  the  patient  be  strong  enough  and  the  weather  dry,  he 
can  be  taken  out  every  day  warmly  dressed  into  the  air. 

Vomiting  is  best  treated  by  suspending  the  mercurial  for  a  few  days. 
If  the  symptom  continue  and  there  be  a  sour  smell  from  the  breath,  the 
diet  must  be  altered,  as  recommended  in  such  cases  (see  Infantile  Atrophy). 
If  looseness  of  the  bowels  occur  and  be  not  arrested  by  stopping  the  medi- 
cine, an  alkali  with  tincture  of  catechu  ^vill  usually  check  the  derangement 
at  once.  Diarrhoea  is  seldom  obstinate  in  these  cases  if  the  diet  be  regu- 
lated and  the  child's  body  be  sufficiently  protected  from  the  cold. 

It  is  important  to  attend  to  the  condition  of  the  nostrils.  All  hard 
crusts  must  be  removed  by  bathing  with  warm  water  after  softening  with 
cold  cream.  An  ointment  of  the  red  oxide  of  mercury  may  then  be  em- 
ployed to  the  inside  of  the  nostrils.  Mucous  patches  must  be  well  touched 
with  the  solid  nitrate  of  silver,  and  if  large  ecthymatous  cnists  have 
formed  on  the  body,  they  must  be  removed  by  poulticing.  The  uncovered 
ulcer  can  then  be  treated  with  the  red  mercurial  ointment. 

Internal  treatment  must  not  be  continued  long  after  the  symptoms  of 
the  disease  cease  to  be  noticed.  On  account  of  the  profound  anaemia  often 
induced  by  the  long-continued  administration  of  mercurials  it  is  v^dse  to 
change  the  treatment  as  soon  as  the  skin  has  recovered  its  healthy  appear- 
ance, and  the  other  specific  symptoms  have  subsided.  Cod-liver  oil  and 
iron  can  then  be  given.  In  addition,  every  care  must  be  taken  to  promote 
healthy  nutrition  by  judicious  regulation  of  the  diet,  and  vigilant  attention 
to  all  the  minor  agencies  which  exert  so  material  an  influence  upon  the 
well-beiaa;  oi  the  infant. 


part  4, 
DISEASE  OF  THE  DUCTLESS  GLANDS  AND  BLOOD. 


CHAPTER  I. 

LEUCOCYTHEMIA. 


Leucocythemia  (leukliffiniia),  although  a  rare  disease  in  childhood,  is  oc- 
casionally seen  in  the  young  subject,  and  therefore  may  be  shortly  de- 
scribed. The  disease  is  characterised  by  great  excess  of  the  leucocytes  of 
the  blood,  enlargement  of  the  spleen,  sometimes  of  the  lymphatic  glands, 
and  a  morbid  state  of  the  bone  medulla.  Two  cases  have  come  under  my 
notice,  both  in  children  imder  three  years  old.  In  each  of  these  the  malady 
assumed  a  febrile  form,  and  was  accompanied  by  enlargement  of  the  spleen 
without  any  apparent  affection  of  the  lymphatic  glands.  In  lymphadenoma, 
which  is  described  elsewhere,  an  increase  in  the  number  of  the  white  cor- 
puscles is  exceptional.  Sometimes,  however,  in  that  disease  excessive  over- 
growth of  lymphatic  elements  is  combined  with  mioltiplication  of  the  colour- 
less blood-cells.  These  cases  present  a  great  resemblance  to  the  lymphatic 
form  of  leucocythemia,  and,  indeed,  anatomically  appear  to  be  almost  in- 
distinguishable from  it.  In  the  present  chapter  the  splenic  form  of 
leucocythemia  will  alone  be  described. 

Causation. — The  etiology  of  leucocythemia  is  not  clear.  Out  of  150 
cases  analysed  by  Dr.  Gowers  in  one-fourth  there  was  a  histor}^  either  of 
ague  or  of  habitation  in  an  ague  district.  Of  my  own  two  cases,  one  had 
lived  at  Malta  ;  the  other  was  a  resident  of  London,  but  had  lived  in  a 
street  in  which  the  roadway  had  been  broken  up  for  repairing  and  relay- 
ing drains  ;  and  for  two  or  three  months  the  upturned  soil,  saturated  with 
coal-gas  and  other  unhealthy  effluvia  had  remained  heaped  up  by  the  side 
of  the  foot-pavement.  The  disease  appeared  shortly  before  the  close  of 
these  operations,  and  I  cannot  but  think  that  the  illness  took  its  rise  in 
the  offensive  emanations  to  which  the  child  had  been  constantly  exposed. 

Morbid  Anatomy. — The  spleen  is  enlarged  and  may  reach  a  great  size. 
This  increase  is  due  to  an  overgrowth  of  the  splenic  pulp,  the  leucocytes 
and  the  fibrous  stroma  being  equally  increased.  The  organ,  although  en- 
larged, retains  its  normal  proportions,  so  that  its  shape  is  not  changed.  Its 
density  is  increased  and  its  colour  is  paler  than  natural.  On  the  surface  it 
is  smooth  unless  local  peritonitis  have  occurred,  in  which  case  particles  of 


LEUCOCYTHEMIA — MOEBID   ANATOMY — SYMPTOMS.  217 

lymph  may  adhere  to  the  capsule.  From  this  cause  it  may  contract  ad- 
hesions to  parts  in  its  neighbourhood.  Its  section  is  smooth  and  of  a 
brownish-yellow  colour  mottled  with  paler  streaks  from  thickened  tra- 
beculse,  and  but  httle  blood  escapes  from  it  on  pressure.  The  Malpighian 
bodies  are  not  very  prominent,  and  may  be  seen  under  the  microscope 
to  be  the  seat  of  fatty  or  lardaceous  degeneration. 

The  liver  is  often  enlarged  from  congestion,  and  may  be  fatty.  The 
kidneys,  too,  are  often  the  seat  of  fatty  degeneration.  Hsemorrhagic  ex- 
travasations are  common,  and  may  be  seen  in  the  skin,  the  heart,  the 
lungs,  the  brain,  and  the  retina,  and  fluid  effusions  may  be  found  in  the 
serous  cavities. 

In  some  cases  the  lymphatic  glands  undergo  slight  enlargement,  but 
the  increase  in  size  is  rarely  universal  as  it  is  in  lymphadenoma.  On 
examination  they  appear  to  be  normal  in  structure  without  any  hyperpla- 
sia of  the  reticulum,  and  suppuration  or  caseation  rarely  occurs.  As  in 
lymphadenoma,  adenoid  growths  may  be  also  found  in  the  tonsils,  the 
foUicles  of  the  tongue,  the  glands  of  the  stomach  and  intestines,  and  in 
other  situations.  The  capillaries  in  various  parts  are  distended  with  col- 
lections of  leucocytes.  The  marrow  of  the  bones  is  more  fluid  than  natural, 
is  grayish  in  colour,  and  shows  an  accumulation  of  white  and  red  corj)us- 
cles.  The  blood  itself  is  much  altered.  It  is  pale  in  colour,  coagulates 
loosely,  and  shows  an  enormous  excess  of  white  corpuscles,  together  with 
a  diminution  in  the  number  of  the  coloured  cells.  Consequently  the  rel- 
ative proportions,  instead  of  being  one  white  to  four  hundred  and  fifty  red, 
as  in  health,  may  fall  to  one  to  twenty,  one  to  ten,  one  to  five,  or  even  to  an 
*  actual  equahty  of  number.  The  white  cells  may  also  present  peculiar  char- 
acters. They  are  sometimes  seen  of  two  quite  different  forms  ;  the  one 
double  the  size  of  the  other  and  full  of  small  fat  granules.  According  to 
Hosier,  this  larger  form  is  evidence  of  morbid  change  in  the  bone  medulla. 
After  death  thick  creamy-looking  clots  may  be  found  in  the  cavities  of  the 
heart,  the  terminal  branches  of  the  pulmonary  artery,  and  the  systemic 
vessels. 

Symjotovis. — The  illness  begins  insidiously.  Sometimes  at  first  the 
general  health  alone  seems  to  be  impau-ed  ;  sometimes  even  from  the  be- 
ginning the  beUy  is  noticed  to  be  large.  The  child  loses  his  sprightliness 
and  begins  to  look  pale  and  to  droop.  His  appetite  fails  and  he  slowly 
wastes.  There  is  almost  always  more  or  less  fever,  but  this  is  at  first 
slight  and  occurs  irregularly.  Afterwards  it  becomes  more  continuous  and 
the  temperature  rises  to  a  higher  level. 

Enlargement  of  the  spleen,  although  not  always  noticed  at  an  early 
period  of  the  disease,  is  usually  to  be  detected  on  careful  examination. 
The  limits  of  the  organ  should  be  always  estimated  by  percussion  as  well 
as  palpation.  The  degree  of  enlargement  varies.  In  neither  of  my  cases 
did  the  lower  edge  reach  more  than  three  fingers'  breadths  below  the  ribs, 
and  there  did  not  seem  to  be  any  great  upward  extension.  In  many  cases, 
however,  the  increase  in  size  is  much  greater.  Some  enlargement  of  the 
liver  may  also  be  noticed. 

When  the  disease  is  fully  developed,  the  child  is  pale  and  weakly  look- 
ing. His  complexion  is  very  white  round  the  mouth  and  eyes,  and  at  the 
sides  of  the  nose  ;  but  often  there  is  a  flush  on  the  cheeks,  which  at  times 
is  noticed  suddenly  to  disappear,  leaving  the  face  ghastly  pale  from  the 
contrast.  Often,  especially  when  the  disease  is  advanced,  there  is  a  pecu- 
liar saUow,  half-jaundiced  tint  of  the  skin.  This  has  been  attributed  to 
the  ana3mia,  the  altered  blood  being  unable  to  destroy  the  bile  pigment 


218  DISEASE   I]N'   CHILDEEE". 

absorbed  into  it  from  tlie  intestine.  The  belly  is  usually  STVoUen  from  flatu 
lent  accumulation,  as  well  as  from  enlargement  of  tlie  liver  and  spleen. 
No  tenderness  is  noticed  on  pressure  of  the  abdomen,  but  if  the  bone 
medulla  is  diseased,  pains  in  tbe  limbs  may  be  complained  of  in  walking. 
Tbere  is  no  loss  of  elasticity  of  the  skin.  The  tougue  is  furred  and  the 
bowels  are  often  capricious.  Sometimes  the  stools  are  loose  and  slimy  ; 
at  other  times  there  is  constipation.  The  child  may  cough,  and  his  breath- 
ing may  be  short ;  but  rmless  a  compHcation  be  jDresent,  examination  of- 
the  chest  discovers  merely  a  little  large-bubbling  rhonchus  at  the  bases  of 
the  lungs.  The-  pulse  is  cpiickened,  especially  at  night.  It  is  usually  over 
100,  sometimes  considerably  so.  In  one  of  my  cases — a  little  boy  aged 
two  years  and  a  quarter — the  xuine  was  high-coloui'ed  and  offensive,  and 
contained  bile,  but  no  albumen.  There  was  some  difficulty  in  holding  it 
at  night. 

The  temperature  rises  in  the  evening  to  between  102°  and  103",  sink- 
ing to  99'  in  the  morning.  The  fever,  however,  is  very  ii'regular,  and  on 
some  days  is  much  higher  than  it  is  on  others.  The  skin  may  be  moist 
at  night,  and  sometimes  there  is  copious  perspii'ation.  An  examination  of 
the  blood  discovers  a  great  excess  in  the  number  of  the  white  coi-puscles. 

As  the  disease  goes  on  the  child  remains  veiy  fi'etful  and  j)iuing.  He 
sleeps  badly  at  night  and  continues  to  lose  flesh.  His  expression  is  veiy 
distressed,  and  his  face  is  white  and  haggai'd.  He  is  thii'sty,  but  cares 
little  for  food.  Often  haemorrhages  come  on,  and  these  effusions  form  a 
very  characteristic  symptom.  The  nose  may  bleed,  or  blood  may  be  dis- 
charged by  the  mouth  or  by  stool.  Although  usually  a  late  symptom, 
hsemoiThage  is  not  always  delayed  until  near  the  close  of  the  illness.  ' 
Epistaxis  is  sometimes  noticed  quite  early  in  the  disease. 

Enlargement  of  lymj)hatic  glands  may  occur,  but  this  is  rarely  con- 
siderable in  a  case  of  pure  splenic  leucocythemia,  and  jDressure  signs  from 
this  cause  are  rarely  noticed.  Towaixls  the  end  of  the  disease  oedema  and 
dropsical  effusions  are  common.  There  may  be  ascites  or  hydrothorax  or 
oedema  of  the  lung,  and  the  lower  hmbs  may  swell  and  pit  on  pressure. 

The  fever  usually  perseveres  to  the  end,  and  the  child  gTows  thinner  and 
weaker.  Various  comphcations  occui*  before  the  close,  especially  croupous 
pneumonia  and  plemisy.  Death  is  often  preceded  by  an  attack  of  convul- 
sions, due,  probably,  to  obstruction  of  the  cerebral  capillaries  by  masses 
of  leucocytes,  as  described  by  Bastian. 

Diagnosis. — The  symj^toms  of  leucocythemia  are  sufficiently  chai-acter- 
istic  of  the  disease.  Ii-regular  pyrexia  and  general  impaii'ment  of  nutri- 
tion, combined  with  a  distressed,  pallid  face,  a  sallow  comjDlexion,  a 
swollen  abdomen,  an  enlarged  spleen  and  liver,  and  the  occurrence  of 
epistaxis  or  melaena,  point  very  distinctly  to  leucocythenda  ;  and  the 
diagnosis  is  at  once  confirmed  by  a  microscopical  examination  of  the 
blood. 

"When  seen  for  the  first  time,  the  case  often  presents  some  resemblance 
to  enteric  fever  ;  and  a  haemorrhage  occuiTing  fi-om  the  bowels  might 
appear  to  confixm  this  view  of  the  illness.  But  the  history,  which  usually 
indicates  disease  of  considerable  standing,  the  complete  absence  of  roey 
spots,  the  enlargement  of  the  hver  as  well  as  of  the  spleen,  the  peculiar 
sallow  tint  of  the  skin — these  symptoms  are  very  unlike  typhoid  fever  ; 
and  if  at  a  late  stage  oedema  of  the  lower  limbs  occurs,  the  presence  of  a 
symptom  so  uncommon  in  enteric  fever  should  make  us  at  least  doubt  the 
correctness  of  this  diagnosis.  An  examination  of  the  blood  showing  a 
large  excess  of  leucocytes  is  of  coui'se  conclusive. 


LEFCOCYTHEMIA — PEOG^fOSIS  —  TREATMENT.  219 

Leucocythemia  may  he  diagnosed  with  certainty  if,  witli  an  enlarged 
spleen,  the  proportion  of  colouiiess  corjDuscles  is  greater  than  one  to  twenty. 
In  a  doubtful  case,  therefore,  it  is  well  to  count  the  corpuscles  with  the 
iKemacytouieter.  If  the  proportion  of  leucocytes  is  less  than  one  to  twenty, 
the  case  may  still  he  one  of  leucocythemia  in  process  of  development ;  and 
as  Dr.  Gowers  has  pointed  out,  to  exclude  this  disease  it  wiU  be  necessaiy 
to  make  repeated  examination  of  the  blood,  and  satisfy  ourselves  that  the 
proportion  is  not  increasing. 

In  cases  where  the  lymphatic  glands  undergo  hypei-plasia,  the  disease 
is  distinguished  from  lymphadenoma  by  noticing  that  the  lymphatic  en- 
largement is  only  moderate,  and  occui's  as  a  late  complication.  Also  that 
the  excess  of  white  corpuscles  in  the  blood  is  very  pronounced.  In  lym- 
phadenoma this  increase  is  either  absent  or  is  comparatively  insignificant. 
Composite  cases  are,  however,  occasionally  met  with,  and  may  be  a  source 
of  perplexity. 

Prognosis.— The  disease  invariably  terminates  fatally  ;  and  the  more 
nearly  the  number  of  the  white  corpuscles  in  the  blood  approaches  to  an 
equality  with  that  of  the  red,  the  gTeater  the  prospect  of  an  early  termi- 
nation to  the  illness.  Haemorrhage,  unless  it  be  from  the  nose,  is  a  very 
gi'ave  symptom. 

Treatment. — No  treatment  has  yet  been  discovered  which  is  capable  of 
arresting  the  progress  of  the  disease.  Ai'senic,  which  is  of  gTeat  value  in 
cases  of  lymphadenoma,  has  no  influence  in  leucocythemia,  and  quinine, 
iron,  and  tonics  generally  have  proved  to  be  cjuite  useless.  Cod-liver  oil 
may,  however,  be  given,  and  is  said  to  be  sometimes  of  temporary  benefit. 
In  an  early  stage  of  the  Olness  faradisation  of  the  splenic  region  for  fifteen 
minutes  twice  a  day  is  said  to  diminish  the  proj^ortion  of  white  corpus- 
cles in  the  blood.  In  a  case  reported  by  Mosler  this  appHcation,  com- 
bined with  the  internal  administi-ation  of  piperine,  oil  of  eucalyptus,  and 
hydroch' orate  of  quinine,  reduced  the  size  of  the  hver  and  spleen  and 
greatly  improved  the  condition  of  the  blood.  Dr.  G.  Y.  Poore  finds  the 
size  of  the  spleen  to  be  diminished  temporaiily  after  faradisation,  but 
states  that  the  therapeutic  benefit  derived  from  the  application  is  very 
transient.  Many  times  a  spleen  which  was  felt  to  be  smaller  and  softer 
immediately  after  galvanism  was  found  after  only  a  few  hours  to  have 
recovered  its  former  size  and  again  become  tense  and  hard.  Dr.  Poore 
states  that  the  leucocytes  in  the  blood  are  increased  in  number  directly 
after  the  application.  Injection  of  various  substances  into  the  spleen  has 
been  attempted,  but  the  results  have  not  been  encoui-aging.  A  case  is  re- 
ported in  which  a  grain  and  a  half  of  salicylic  acid  was  injected  into  the 
organ,  and  the  patient  died  six  hom-s  afterwards. 

Excision  of  the  spleen  has  been  tried,  but  has  invariably  led  to  such 
effusion  of  blood  that  the  death  of  the  patient  has  very  cpiickly  followed. 
All  we  can  do  is  to  treat  distressing  symptoms  as  they  arise,  and  to  sup- 
ply the  patient  with  such  nutritious  food  as  his  stomach  can  digest.  Quiet 
is  very  important  when  the  ansemia  is  great.  Looseness  of  the  bowels 
must  be  treated  with  small  doses  of  rhubarb  and  the  aromatic  chalk  pow- 
der, or  with  dilute  sulphuric  acid  ;  oedema  with  digitalis  and  diuretics  ; 
hsemorrhage  with  the  ordinary  styptics.  If  the  pain  is  complained  of  over 
the  spleen,  it  is  best  reheved  by  counter-irritation  and  anodyne  apphcations, 
such  as  smearing  the  sm-face  with  equal  parts  of  the  extract  of  belladonna 
and  glycerine,  covering  the  side  afterwards  with  cotton-wool. 


CHAPTER  11. 

LYMPHADENOMA. 

Lyjiphadenoma  (adsenia,  lymphatic  anaemia,  Hodgkin's  disease)  is  one 
of  the  less  common  diseases  of  early  life,  but  it  occurs  sufficiently  often 
to  render  the  affection  a  not  unfamiliar  one  in  Children's  Hospitals.  Lym- 
phadenoma  consists  in  a  hyperplasia  of  lymj)hatic  tissue  in  various  parts 
of  the  body,  even  in  situations  where  such  structures  do  not  normally 
exist  in  any  great  quantity.  The  lym^Dhatic  glands  are  chiefly  involved, 
but  the  spleen,  liver,  and  kidneys  maj^  be  greatly  enlarged  and  altered  in 
structure.  If  the  enlargement  be  hmited  to  a  few  glands  or  organs,  the 
disorder  may  have  the  characters  of  a  local  comj)laint.  Usually,  however, 
the  affection  spreads  very  extensively  and  exhibits  all  the  phenomena  of  a 
general  disease,  being  attended  with  fever,  wasting,  great  and  increasing 
pallor,  and  marked  weakness.     In  the  end  it  is  almost  invariably  fatal. 

Causation. — The  causes  of  lymphadenoma  are  obscure.  Diathetic  ten- 
dencies have  been  supposed  to  give  rise  to  the  disease,  and  there  is  no 
doubt  that  in  some  cases  pulmonary  consiunption  or  syphilis  has  been 
noted  in  the  parents.  In  other  cases,  however,  the  family  history  has 
been  good.  Acute  disease  in  the  child  himself  has  sometimes  appeared  to 
be  the  starting-point  for  a  slow  deterioration  of  health  which  has  event- 
ually developed  into  undoubted  lymphadenoma.  So  also  the  occurrence 
of  the  illness  has  been  attributed  to  bad  or  insufficient  food  or  insanitary 
conditions  generally.  In  some  cases,  however,  no  sufficient  cause  has 
been  discovered  to  account  for  the  failure  of  health.  The  disease,  hke 
tuberculosis,  with  which  it  presents  certain  affinities,  may  develop  without 
apparent  reason  in  a  child  whose  health  had  previously  given  no  cause  for 
anxiety. 

In  not  a  few  cases  some  local  derangement  or  injury  has  appeared  to 
be  the  exciting  cause  of  the  enlargement  of  the  lymphatic  glands.  Thus 
a  decayed  tooth,  a  j)atch  of  eczema,  an  otorrhoea — all  these  have  been 
known  to  be  quickly  followed  by  a  swelling  of  the  glands  in  the  neighbour- 
hood of  the  irritant.  In  scrofulous  subjects  a  persistent  caseous  enlarge- 
ment of  glands  from  this  cause  is  not  uncommon.  In  lymphadenoma, 
however,  the  morbid  changes  do  not  remain  hmited  to  the  neighbourhood 
of  the  irritant.  Others  more  distant  from  the  seat  of  irritation  take  on 
the  same  unhealthy  action,  and  thus  the  disease  spreads  widely  so  as  to 
involve  adenoid  tissue  in  all  parts  of  the  body. 

The  age  of  the  children  affected  is  usually  four  or  five  years  and 
upwards.  I  have,  however,  seen  a  well-marked  case  in  an  infant  eight 
months  old,  who  had  begun  to  suffer  at  the  age  of  three  and  a  half 
months. 

Morbid  Anatomy. — After  death  in  a  case  of  lymphadenoma  we  usually 
find-  gTeat  enlargement  of  the  lymphatic  glands,  and  often  of  the  spleen, 
the  Uver,  and  the  kidneys.     In  addition  there  is  commonly  overgTOwth  of 


LTMPHADENOMA — MOEBID   ANATOMY.  221 

the  more  minute  collections  of  adenoid  tissue  in  various  parts  of  the  body, 
as  in  the  tonsils,  the  pharynx,  the  gullet,  the  stomach  and  intestines,  etc. 
Of  these  the  more  considerable  enlargements  are  often  limited  to  a  com- 
paratively few  organs  and  structures,  but  microscopical  examination  dis- 
covers very  wide-spread  changes  in  parts  which  present  little  or  no  apparent 
alteration  to  the  unassisted  sight. 

The  lymphatic  glands  are  greatly  enlarged,  and  the  enlargement  may 
be  in  two  forms — a  hard  and  a  soft  swelling.  This  difference  appears 
to  depend  less  upon  the  nature  of  the  gTowth  than  upon  the  rapidity  of 
its  progress,  for  the  two  varieties  may  be  found  combined  in  the  same 
subject. 

The  size  of  the  swoUen  glands  commonly  varies  from  a  hazel-nut  to  a 
hen's  egg,  but  in  exceptional  cases  the  growth  may  reach  still  more  con- 
siderable dimensions.  The  first  glands  to  be  affected  are  usually  those  in 
the  neck.  Then  follow  in  order  of  frequency  the  axillary,  inguinal,  retro- 
peritoneal, bronchial,  mediastinal,  and  mesenteric.  But  besides  enlarge- 
ment of  glands,  circumscribed  growths  may  be  developed  in  sjDots  where, 
although  adenoid  tissue  exists  normally  in  small  quantity,  it  is  not  col- 
lected into  glandular  masses.  By  this  means  the  various  grou^DS  of  enlarged 
glands  may  be  found  connected  together  by  chains  of  newly  developed 
lymphatic  nodules. 

When  a  group  of  glands  takes  on  the  morbid  process,  the  individual 
bodies  at  first  remain  distinct  and  are  movable.  As  the  disease  progresses 
they  cease  to  be  movable,  and  eventually  become  welded  together  into  a 
solid  mass.  The  process  of  union  consists  in  a  disappearance  of  the  cap- 
sule, which  becomes  pierced  and  ultimately  almost  destroyed  as  the  new 
lymphatic  tissue  accumulates.  On  examining  such  a  mass  the  outline  of 
diseased  glands  can  be  recognized  here  and  there  by  a  thin  fibrous  capsule, 
but  the  confluence  is  for  the  most  part  comjjlete,  and  no  intervening  infil- 
•  tration  can  be  discovered.  On  the  surface  the  mass  is  often  very  irregular 
and  nodulated,  and  may  be  mottled  with  white  or  yellow  patches,  but 
caseation  is  seldom  seen.  If  the  mass  be  superficial  it  may  be  adherent  to 
the  skin.  In  rare  cases  it  suppurates.  The  greater  or  less  hardness  of  the 
enlarged  gland  is  determined,  as  has  been  already  said,  by  its  rapidity  of 
development.  If  it  grows  very  quickly  the  gland  is  soft.  On  section  of 
such  a  gland  the  substance  appears  often  to  be  almost  diffluent.  If  firmer, 
it  yields  a  creamy  juice  when  scraped.  If  very  firm  the  hardness  is  found 
to  be  due  to  hyperplasia  of  the  fibrous  stroma,  dense  bands  of  fibrous  tis- 
sue running  in  various  directions  through  the  mass. 

Under  the  microscope  the  morbid  change  in  the  glands  is  seen  to  con- 
sist in  an  enormous  increase  in  the  lymph  corpuscles.  These  accumulate, 
and  by  their  pressure  may  perforate  the  capsule  and  even  split  up  the 
septa  and  cause  them  to  disappear.  In  the  softer  growths  the  diseased 
process  is  chiefly  of  this  kind.  In  the  firmer  glands  there  is  an  increase  in 
the  fibro'us  stroma,  which  becomes  greatly  thickened.  The  hypertrophy 
may  even  obliterate  the  meshes  of  the  reticulum  and  convert  the  organ 
into  a  mass  of  fibrous  tissue. 

The  spleen  commonly  suffers,  especially  if  the  disease  begins  in  the 
lymphatic  glands  of  the  neck.  The  organ  becomes  greatly  enlarged.  Its 
normal  lymphatic  tissue  fakes  on  a  rapid  growth,  and  shows  the  same  ten- 
dency to  fibrosis  that  is  noticed  in  the  glands.  Extei-nally  the  organ  is  of 
a  dull  reddish  colour  with  paler  patches,  and  yellow  spots  from  the  size 
of  a  mustard-seed  upwards  are  often  seen  scattered  over  the  surface.  To 
the  touch  it  is  usually  dense  and  firm.     On  section  whitish  or  yellow  nod- 


222  DISEASE   IN   CHILDEEN. 

ules  are  discovered  on  a  dark-red  ground.  The  nodules  are  more  or  less 
closely  aggregated  so  as  to  form  masses  of  varying  size  and  shape.  The 
new  material  appears  to  oiiginate  in  the  Maljoighian  follicles  and  the  peri- 
arterial sheaths  of  lymjohoid  tissue.  It  is  composed  of  lymphoid  cells  and 
large  quantities  of  impei'fect  fibrous  tissue.  The  fibrous  stroma  is  6ften 
thickened,  and  may  show  bands  of  fibrous  tissue  without  definite  arrange- 
ment, or  running  loosely  parallel  so  as  to  form  oval  loculi  by  their  diver- 
gencies. In  a  late  stage  the  bands  are  sometimes  pigmented  at  their 
edges.  Under  the  microscope  these  bands  appear  to  be  formed  by  rapid 
induration  of  a  lymphatic  tissue  growing  around  the  vessels. 

In  the  liver  the  new  growth  usually  appears  in  the  form  of  small,  irreg- 
ular, infiltrating  masses  which  may  project  as  irregular  prominent  patches 
on  the  surface.  The  structure  of  these  growths  is  similar  to  that  of  the 
new  material  in  other  parts,  but  in  this  organ  there  appears  to  be  a  greater 
tendency  to  caseation.  The  lymphatic  new  growth  occupies  the  interlobu- 
lar spaces.  In  a  case  reported  by  Dr.  Greenfield  it  seemed  to  start  in  the 
portal  canals  as  small  masses  which  extended  around  and  into  the  lobules, 
the  liver-cells  becoming  degenerated  and  shrivelled. 

When  the  kidneys  are  affected  the  organs  are  enlarged  and  often  irreg- 
ular in  shaj^e.  Their  colour  is  light  yellow  or  even  dull  white,  and  ecch}^- 
moses  may  be  scattered  over  the  surface.  Sometimes  signs  of  more  profuse 
haemorrhage  are  found,  and  large  purple  blotches  are  seen  through  the 
capsule  on  the  pale  surface  of  the  gland.  On  section  the  cortical  substance 
is  more  or  less  swelled,  and  is  of  a  yellowish-white  colour  mottled  with 
points  and  patches  of  red.  By  the  microscope  an  excess  of  adenoid  tissue 
is  seen  between  the  tubules,  sometimes  separating  them  widety.  The 
growth  is  collected  in  large  quantities  around  the  glomeruli,  and  in  some 
cases  the  new  tissue  appears  to  pass  along  the  vessels  into  the  interior  of 
the  Malpighian  capsule.  In  both  liver  and  kidneys  it  is  common  to  find 
blood-vessels  blocked  by  masses  of  colourless  corpuscles.  , 

The  new  growths  developed  in  places  where  adenoid  tissue  exists  nor- 
mally in  minute  quantity  are  usually  rather  soft  and  elastic.  They  are  of 
a  pinkish  colour  and  very  vascular.  Such  local  developments  of  lymj)hatic 
tissue  may  be  seen  in  the  tonsils,  at  the  back  of  the  jDharynx,  and  in  the  gul- 
let, stomach,  and  intestines,  originating  in  the  follicular  glands.  All  these 
often  undergo  ulceration.  Growths  have  also  been  found  in  the  testicles, 
peritoneum,  omentum,  pleura,  and  in  the  lungs.  In  the  latter  situation 
they  often  break  down  and  form  cavities. 

When  the  hlood  is  examined  microscopically  the  red  corpuscles  are 
seen  to  be  very  pale  in  colour,  but  they  usually  form  rouleaux  in  the  or- 
dinary manner.  Amongst  them  are  corpuscles  of  much  smaller  diameter. 
The  red  corpuscles  are  considerably  reduced  in  quantity',  but  there  is  sel- 
dom any  material  addition  to  the  number  of  white  corpuscles :  indeed,  in 
many  cases,  like  the  red  cells  they  are  diminished  in  number.  Sometimes, 
however,  the  leucocytes  may  appear  to  be  slightly  more  numerous  than  in 
the  healthy  subject ;  but  even  if  the  spleen  be  greatly  enlarged,  no  increase 
sufficient  to  constitute  leucaemia  is  observed  in  cases  of  true  lymphade- 
noma,  and  the  white  (3ells  never  present  the  altered  characters  which  are 
noticed  in  the  former  disease.  As  a  rule,  a  greater  excess  of  white  corpus- 
cles is  seen  in  cases  where  the  lymphatic  growth  is  of  the  soft  variety  than 
where  it  is  hard  and  chiefly  fibrous.  Forms  of  mixed  disease  are  also 
sometimes  met  with  in  which  there  is  increase  in  quantity  of  the  splenic 
pulp.     The  afl'ection  has  then  some  of  the  characters  of  leucocythemia. 

Symptoms. — The    symptoms  of   lymphadenoma  may  be  divided  into 


LYMPHADENOMA — SYMPTOMS.  223 

those  proper  to  the  illness,  which  may  be  called  the  regular  symptoms, 
and  those  which  are  irregular  and  accidental,  being  the  consequence  of  the 
pressure  set  up  by  the  growths  upon  the  parts  around. 

The  regular  symptoms  consist  of  the  general  constitutional  disturbance 
excited  by  the  disease,  the  changes  in  the  state  of  the  blood,  and  the  pres- 
ence of  enlarged  lymphatic  glands. 

The  general  constitutional  symptoms  may  precede  or  follow  signs  of 
enlargement  of  glands.  They  consist  of  a  febrile  movement  more  or  less 
high,  with  gradually  increasing  wasting,  pallor,  and  loss  of  strength. 

A  little  boy,  aged  three  years,  was  under  the  care  of  my  former  col- 
league. Dr.  MitcheU  Bruce,  in  the  East  London  Children's  Hospital.  The 
child  had  been  ill  and  languid  for  three  months  before  admission,  gradu- 
all}''  wasting  and  suffering  from  occasional  attacks  of  diarrhoea.  When 
brought  to  the  hospital  he  was  weakly,  with  a  pale  complexion  and  hag- 
gard, anxious  look.  His  face  often  flushed  up  suddenly  ;  his  skin  gener- 
ally was  harsh  and  dry.  At  first  no  special  disease  of  organs  could  be 
discovered.  The  spleen  could  be  felt  projecting  about  half  an  inch  below 
the  ribs,  the  liver  was  normal  in  size,  and  no  enlargement  of  the  lym- 
phatic glands  was  noticed.  The  boy  coughed  occasionally,  but  the  phys- 
ical signs  about  his  chest  were  normal.  His  temperature  on  the  first 
evening  was  101.4°,  and  continued  to  stand  at  much  the  same  level  for 
some  time.  It  sometimes  sank  to  99°  and  at  other  times  rose  suddenly 
for  a  few  hours  to  104°,  but  it  usually  varied  between  100°  and  101°.  The 
boy  continued  in  much  the  same  state,  being  usually  apathetic  and  dull, 
although  he  brightened  up  a  little  at  times  and  would  pla}^  listlessly  with 
his  toys.  The  course  of  the  illness  was  very  variable,  and  the  child  seemed 
much  worse  at  some  times  than  at  others.  Once  or  twice  he  seemed 
decidedly  better  and  regained  a  few  ounces  of  his  weight,  then  he  relapsed 
and  wasted,  rapidly  losing  a  pound  and  a  half  in  a  week.  Often  he  was 
drowsy,  and  his  aj^petite  was  always  poor. 

As  time  went  on  the  liver  and  spleen  became  moderately  swollen,  signs 
of  enlargement  of  the  bronchial  glands  were  noticed,  and  deep  pres- 
sure in  the  abdomen  discovered  some  enlargement  of  the  mesenteric 
glands. 

The  bowels  remained  more  or  less  loose.  The  boy  grew  slowly  weaker, 
and  died  after  a  residence  of  four  months  and  a  half  in  the  hospital. 
There  was  never  any  oedema  of  the  limbs,  and  the  glands  in  the  neck  were 
not  affected. 

On  examination  of  the  body  after  death,  large  yellow,  cheesy-looking 
masses  were  found  adherent  to  the  under  surface  of  the  breast-bone,  and 
the  anterior  mediastinum  was  filled  with  a  large  mass  of  agglutinated 
glands.  A  similar  mass  was  found  in  the  abdomen  in  front  of  the  spine 
just  below  the  diaphragm  and  surrounding  the  head  of  the  pancreas.  The 
liver  was  large,  soft,  and  flabby  to  the  touch.  Its  section  showed  a  half 
translucent  appearance,  and  on  close  inspection  this  was  found  to  be  due 
to  a  multitude  of  closely  set  little  masses,  the  size  of  a  pin's  head  or  less, 
some  clear  and  transparent,  others  more  yellow.  The  spleen  also  was 
large,  and  its  section  showed  the  appearance  usually  noticed  in  this  disease 
and  which  has  been  already  described.  Both  lungs  were  found  on  section 
to  be  pervaded  with  small  masses  of  new  adenoid  growth. 

In  this  case  the  general  symptoms  preceded  the  signs  of  local  mischief. 
Often,  however,  especially  if  the  illness  begins,  as  it  commonly  does,  with 
enlargement  of  the  cervical  glands,  the  affection  has  at  first  the  chai-acters 
of  a  local  disease.     But  sooner  or  later,  as  the  lymphatic  tissue  becomes 


224  DISEASE   IN   CHILDEElSr. 

more  and  more  involved,  the  patient  begins  to  suffer  from  irregular  fever 
and  grows  very  decidedly  anaemic. 

The  glandular  swellings  in  the  neck  usually  form  an  irregular  nodular 
mass  which  may  extend  from  one  side  to  the  other,  passing  underneath  the 
chin,  or  may  be  limited  principally  to  one  side.  At  first  the  individual 
glands  can  be  made  out,  and  the  masses  are  movable.  Afterwards  the  glands 
become  more  welded  together  and  the  masses  are  fixed.  The  swellings  are 
painless,  and  unless  of  very  rapid  growth  are  dense  and  firm  to  the  touch. 
In  some  cases  a  mass  of  enlarged  glands  wiU  become  A^ery  soft  and  suppu- 
rate, forming  an  abscess  which  discharges  and  heals  up  in  the  ordinary 
manner.  Besides  the  neck,  enlarged  glands  may  be  felt  in  the  axillfe  and 
groins.  In  the  armpits  the  size  of  the  growths  may  interfere  wdth  the 
movements  of  the  arms.  Examination  of  the  chest  and  belly  often  dis- 
covers a  similar  change  in  the  glands  lying  in  the  anterior  mediastinum 
and  abdomen.  The  enlargement  of  the  liver  and  spleen  is  usually  mod- 
erate, although  sometimes — especially  in  the  case  of  the  latter  organ — it 
may  be  very  considerable. 

While  the  disease  is  limited  to  swelling  of  a  few  glands  in  the  neck, 
the  child,  although  pale,  may  be  active  and  cheerful,  ajoparently  suffering 
in  no  way  except  from  the  local  inconvenience.  When,  however,  the 
glands  grow  rapidly,  or  the  disease  spreads  from  the  neck  to  other  parts 
of  the  body,  constitutional  symptoms  begin  to  be  noticed.  Fever  is  almost 
mvariably  present,  although  in  the  earlier  stage  it  is  slight  and  intermittent. 
In  the  cachectic  stage  the  temperatiu'e  often  rises  to  a  high  level,  and 
for  a  few  days  together  may  range  between  103°  and  105°,  sometimes  even 
passing  the  higher  limit.  Sweating  is  not  common  ;  indeed,  in  most  cases 
the  skin  is  excessively  harsh  and  dry.  The  digestive  organs  almost  inva- 
riably suffer.  The  tongue  is  covered  with  a  white  fur,  and  the  papillae  are 
prominent  and  red.  Ulcerative  stomatitis  may  be  present  on  the  inner' 
side  of  the  cheek.  The  appetite  is  poor  and  indigestion  and  vomiting  may 
be  com2Dlained  of.  The  bowels  are  sometimes  costive,  but  often  they 
are  loose,  and  the  dejections  may  be  preceded  by  griping  pains  in  the 
belly.  The  looseness  is  due  in  many  cases  to  small  ulcerations  of  the  ileum. 
There  is  then  usually  abdominal  swelling,  increased  tension  of  the  parie- 
ties,  and  tenderness  on  pressure.  More  or  less  cough  is  a  common  symp- 
tom, and  an  examination  of  the  chest  often  discovers  signs  of  consolida- 
tion and  softening.  These  lesions  commonly  result  from  growths  in  the 
lung  which  soften  and  break  down  into  cavities. 

Great  apathy  and  dulness  of  mind  are  in  many  cases  associated  wdth 
the  cachectic  stage  of  the  disease.  The  child  may  he  found  to  sleep  almost 
constantly,  his  senses  seem  dulled,  and  his  w^ants  are  so  httle  pressing 
that  he  asks  for  nothing  and  makes  no  comj^laint.  Indeed,  sometimes  it  is 
most  dif&cvTlt  to  get  him  to  speak  at  all.  The  urinary  function  is  rarely 
interfered  with,  but  sometimes  blood  is  passed  with  the  urine.  In  a  case 
reported  by  Dr.  Goodhart — a  little  girl  aged  ten  months — the  child's  water 
towards  the  end  of  the  disease  became  red  with  blood. 

The  anaemia  is  usually  extreme.  The  whole  surface  of  the  body  is  ex- 
cessively pale,  and  the  mucous  membranes  are  singularly  bloodless.  Pur- 
puric spots  may  be  found  on  the  body,  face,  and  limbs,  and  sometimes 
larger  dark  purplish  blotches  are  seen  from  more  extended  extravasation. 
Flushing  of  the  face  is  a  common  symptom,  and  a  redness  of  the  cheeks  at 
this  time  forms  a  curious  contrast  with  the  dead  whiteness  persisting  round 
the  mouth  and  eyes.  A  microscopic  examination  of  the  blood  shows  the 
diminution  in  the  number  of  the  red  corpuscles  which  has  been  already 


LYMPHADEJSrOMA — SYMPTOMS. 

referred  to.  The  white  corpuscles  are  rarely  in  notable  excess.  As  a  con- 
sequence of  the  anaemia  oedema  may  occur  in  the  limbs,  and  there  may  be 
ascites.  Pressure  of  the  enlarged  glands  upon  the  venous  trunks  may  also 
aid  in  the  production  of  serous  eftusion. 

A  good  example  of  the  more  common  form  of  the  disease,  where  the 
general  constitutional  disturbance  occurs  subsequently  to  the  primary 
glandular  enlargement,  was  seen  in  the  case  of  a  little  boy,  aged  thirteen 
years,  who  was  under  the  care  of  my  colleague,  Dr.  Donkin,  in  the  East 
London  Children's  Hospital.  The  boy  came  of  a  healthy  family  and  had 
himself  been  strong  and  healthy  until  the  age  of  eight  years,  when  he  was 
laid  up  for  three  months  in  consequence  of  a  fall  on  his  head  and  spine, 
in  this  illness  the  lad  could  not  rest  on  his  back  or  side,  but  was  obliged  to 
lie  on  his  face.  Although  he  began  to  walk  again  in  two  months'  time,  and 
was  convalescent  at  the  end  of  the  third  month,  he  never  recovered  his 
strength  completely.  Twelve  months  after  his  illness  he  was  again  laid 
up  with  pains  in  the  chest  and  swelling  of  the  face  and  arms.  The  swell- 
ing soon  subsided,  but  the  boy  remained  weak  and  complaining  and  was 
often  under  medical  treatment. 

On  admission  the  patient  complained  of  lumps  in  his  neck  which  he 
stated  were  of  three  years'  duration.  For  three  months  he  had  been  losing 
flesh  and  his  belly  had  been  growing  larger.  His  skin,  he  said,  had  been 
dry  for  some  time.  His  legs  had  never  swelled,  but  he  had  noticed  a  swell- 
ing of  his  scrotum  for  three  or  four  days.  He  was  subject  to  cramp-like 
pains  about  the  umbilicus  which  were  often  severe,  and  the  belly  at  these 
times  was  tender.  He  had  had  a  cough  for  a  month  without  expectoration, 
and  his  b6wels  had  been  relaxed  for  a  week. 

On  examination  the  boy  was  found  to  be  very  thin,  and  his  skin  was 
dry,  rough,  and  furfuraceous,  especially  about  the  belly.  The  cervical  and 
submaxillary  glands  were  enlarged  on  both  sides  so  as  to  form  a  collar 
round  the  neck.  The  axillary  and  inguinal  glands  were  normal.  No  en- 
largement of  the  liver  or  sjDleen  was  noticed.  The  abdomen  was  distended, 
with  fulness  of  the  superficial  veins.  There  was  some  tenderness  on 
pressure  below  the  umbilicus,  and  the  tension  of  the  parieties  was  in- 
creased. No  growth  could  be  felt  in  the  belly,  and  there  was  at  first  no 
ascites.  There  was  some  oedema  of  the  scrotum,  but  none  of  the  arms  or 
legs.  The  tongue  was  red  and  rather  raw-looking,  and  some  superficial 
ulceration  was  noticed  at  the  angles  of  the  mouth  and  inside  the  left 
cheek.  The  bowels  were  relaxed,  the  stools  being  loose  and  lightish  yel- 
low in  colour.  There  were  signs  of  consolidation  of  the  right  lung.  The 
urine  was  pale,  slightly  alkaline,  but  contained  no  albumen.  An  examin- 
ation of  the  blood  showed  the  absence  of  any  excess  of  white  corpuscles. 

After  admission  the  boy  remained  in  a  very  apathetic  state,  and  whether 
up  or  in  bed  seemed  to  be  always  drowsy.  He  would  be  found  asleep 
with  his  head  on  his  arms  or  curled  up  on  a  sofa.  His  face  was  habitually 
very  pale,  but  at  times  it  would  flush  up  irregularly.  He  coughed  occa- 
sionally, and  expectorated  tenacious  mucus.  His  temperature  was  always, 
high,  rising  at  night  to  103°  or  104°.  He  continued  to  waste  and  grow 
weaker.  Death  was  hastened  by  a  severe  attack  of  vomiting  which  pro- 
duced great  prostration,  and  he  died  soon  afterwards. 

After  death  the  cervical,  bronchial,  retro-peritoneal,  and  mesenteric 
glands  were  found  to  be'  enormously  enlarged,  forming  agglomerated 
masses  in  which,  however,  individual  glands  could  still  be  made  out.  The 
enlarged  glands  were  very  tough.  On  section,  the  larger  number  were  of 
yellowish  tint  and  seemed  fibrous,  but  a  few  were  grayish  and  translucent. 
15 


226  DISEASE   IN   CHILDEEN. 

Some  contained  caseous  matter.  New  growths  very  similar  in  appearance 
were  found  in  the  pleura  and  peritoneum.  There  were  some  ulcers  in  the 
ilium  and  caecum.  The  follicles  of  the  tongue  were  swollen.  Both  tonsils 
were  large  and  ulcerated.  SmaU  ulcers  were  found  on  the  anterior  wall  of 
the  trachea  ;  and  on  the  posterior  surface  of  the  epiglottis  were  yellowish 
infiltrations  of  a  roundish  shape.  All  the  mucous  membrane  in  this  neigh- 
boui'hood  was  highly  injected.  Both  lungs  were  the  seat  of  consolidation 
which  had  broken  down  into  cavities.  The  spleen  was  large,  soft,  and  con- 
gested. The  Malpighian  tufts  were  not  visible.  The  kidneys  and  liver 
were  normal.     The  marrow  of  the  right  femur  was  mottled,  red,  and  gi'ay. 

The  irregular  or  accidental  s}Tnptoms  arise  from  pressure  set  up  by 
enlarged  glands  or  organs  upon  adjacent  parts.  Thus  the  swollen  glands 
in  the  neck  may  press  upon  the  jugular  veins,  and  by  impeding  the  es- 
cape of  blood  from  the  interior  of  the  skull,  cause  heaviness,  drowsi- 
ness, oedema  of  the  head  and  neck,  and  epistaxis.  They  may  also  ham- 
per the  movements  of  the  lower  jaw,  press  the  larynx  and  trachea  to 
one  side,  and  cause  dyspnoea  by  theu-  interference  with  the  air-passages. 
Sometimes  they  obstruct  the  channel  of  the  gullet  so  that  food  passes  with 
difficulty  or  swallowing  becomes  actually  imjDossible.  Enlargement  of  the 
iDronchial  glands  may  produce  dyspnoea,  spasmodic  cough,  and  all  the 
symptoms  which  have  been  enumei-ated  elsewhere  as  the  consequence  of 
pressui-e  within  the  chest  (see  page  181).  Growths  of  the  mesenteric 
glands  may  set  up  ascites  and  jaundice  by  their  pressiu-e  on  the  bile-ducts 
or  portal  vein,  and  oedema  of  the  scrotum  and  lower  limbs  by  their  inter- 
ference with  the  return  of  blood  through  the  inferior  vena  cava. 

Paralysis  has  been  occasionally  fioticed.  Thus  Dr.  Goodhart  has  reported 
the  case  of  a  little  boy,  aged  six,  who  was  admitted  a  patient  under  Dr. 
Pav;^',  in  Guy's  Hospital,  for  complete  paraplegia,  with  incontinence  of  urine 
and  deficiency  of  sensation  below  the  umbilicus.  After  death  a  lympho- 
matous  growth  was  found  in  the  thorax,  w^hich  had  entered  the  spinal 
canal  in  the  dorsal  region  by  passing  through  the  intervertebral  foramina. 
Here  it  had  lined  the  laminae  of  the  vertebrte  from  the  axis  to  the 
eighth  cervical  segment.  In  addition  it  had  formed  a  mass  which  at  one 
point  completely  filled  the  canal,  compressed  the  cord,  and  had  formed 
adhesions  with  the  cord  and  the  dura  mater.  Below  this  point  the  sub- 
arachnoid tissue  was  distended  with  fluid. 

In  a  case  which  was  under  my  own  care  in  the  East  London  Children's 
Hospital — a  boy  ten  years  old,  who  suffered  from  an  enormous  mass  of 
enlarged  cervical  glands  on  the  right  side  of  the  neck,  besides  lesser  en- 
largement of  the  mesenteric  and  inguinal  glands — for  some  weeks  be- 
fore the  child's  death  ptosis  was  noticed  of  the  right  eyelid,  and  on  exam- 
ination it  was  found  that  the  pupil  of  that  eye  was  somewhat  dilated, 
and  that  there  was  paralysis  of  the  internal  rectus.  At  times,  too,  the  boy 
complained  of  severe  neuralgic  pains  in  the  right  eyeball.  After  death, 
inspection  of  the  body  showed  a  mass  the  size  of  a  walnut,  which  lay  in 
the  middle  cerebral  fossa,  and  was  adherent  to  the  dura  mater  covering  the 
cavernotis  sinus.  The  mass  had  a  prolongation  which  passed  through 
the  foramen  lacerum  medium  and  joined  the  general  glandular  mass  in 
the  neck.  Its  pressure  upon  the  right  third  nerve  had  caused  some 
atrophy  of  the  nerve — for  it  was  appreciably  thinner  than  that  on  the  left 
side — and  had,  no  doubt,  given  rise  to  the  paralytic  symptoms  which  had 
been  noticed  during  Ufe. 

The  duration  of  a  case  of  lymphadenoma  is  very  variable.  When  the 
illness  begins  as  a  local  disease,  the  course  is  usually  very  slow  at  the  fii'st. 


LYMPH  ADENOMA — DIAGNOSIS — TEEATMENT.  227 

and  it  may  be  years  before  the  general  glandular  system  becomes  affected. 
"When,  however,  the  cachectic  stage  begins,  the  course  is  more  acute. 
Still,  the  progress  of  the  malady  is  always  variable,  and  growth  is  more 
rapid  at  some  times  than  at  others.  In  the  child  the  general  disease 
rarely  lasts  longer  than  six  or  eight  months.  Death  may  result  from  asthe- 
nia or  from  some  complication,  as  pneumonia,  pleurisy,  vomiting,  or  'diar- 
rhoea. It  may  be  preceded  by  convulsions.  Sometimes  the  end  is  has- 
tened by  the  injurious  effects  of  mechanical  ]3ressure  upon  the  air-passages, 
the  gullet,  or  the  large  veins  of  the  abdomen. 

Diagnosis. — In  the  diagnosis  of  a  case  of  lymphadenoma  we  have  to 
search  for  evidence  of  general  affection  of  the  glandular  system.  So 
long  as  the  disease  remains  limited  to  a  few  glands  of  the  neclc  the  nature 
of  the  swelling  is  not  always  easy  to  ascertain  ;  but  even  at  this  time  it 
may  be  sometimes  distinguished  by  the  elasticity  of  the  growth,  for,  ac- 
cording to  Birch-Hirschfeld,  even  in  the  harder  variety  of  lymjDhadenoma 
there  is  a  certain  elasticity  as  compared  with  the  dense,  boardlike  hard- 
ness of  the  cheesy  gland.  Moreover,  there  is  no  inflammation  set  up 
round  the  mass,  and  caseous  degeneration  and  softening  are  very  rare. 
In  a  group  of  scrofulous  glands  some  usually  soften  early  and  form  an  ab- 
scess.    In  such  a  case,  too,  the  general  signs  of  scrofula  may  be  noticed. 

Sarcomatous  glands  present  a  greater  likeness  to  lymphadenoma  ;  but 
when  extension  takes  place  in  the  former  disease  the  tissues  involved  are 
not  especially  the  lymphatic  tissues  ;  indeed,  the  disease  tends  to  spread 
rather  to  organs  than  to  glands. 

In  the  cachectic  stage  lymphadenoma  is  usually  easy  of  recognition. 
The  irregular  fever,  the  extreme  pallor,  the  great  drowsiness  and  unwill- 
ingness to  speak,  the  general  implication  of  lymphatic  glands  in  all  parts 
of  the  body,  the  character  of  the  blood,  which  shows  diminution  in  the 
number  of  red  corpuscles  with  no  or  only  slight  increase  in  the  proportion 
of  leucocytes.     These  symptoms  are  sufficiently  characteristic. 

Prognosis. — Although  some  cases  of  recovery  from  this  disease  have 
been  recorded,  the  illness  is  so  generally  fatal  that  little  hope  of  a  favour- 
able issue  can  be  entertained.  In  the  cachectic  stage  speedy  death  may 
be  anticipated.  In  the  earlier  period  a  prolonged  course  may  be  hoped 
for,  especially  if  the  enlargement  is  slow  ;  but  it  is  unwise  to  speak  too 
favourably  even  of  this  prospect,  for  the  disease  may  at  any  time  suddenly 
assume  an  acuter  character,  and  variations  in  the  rapidity  of  its  progress 
are  not  uncommon.  Examination  of  the  blood  may  be  of  some  service  in 
estimating  the  probabilities  of  a  lengthened  course.  If  the  number  of  red 
corpuscles  is  greatly  reduced,  the  child's  prospects  are  very  unfavourable. 

Treatment. — In  every  case  the  child  should  be  put  into  as  good  sanitary 
conditions  as  possible,  and  every  effort  should  be  made  to  improve  the 
general  health.  Cod-liver  oil,  iron,  quinine,  and  tonics  generally  are  use- 
ful in  this  respect,  but  none  of  these  remedies  have  the  power  of  delajdng 
materially  the  progress  of  the  disease  after  the  affection  of  the  lymphatic 
glands  has  become  general.  Arsenic,  however,  is  highly  spoken  of  for  its 
value,  even  in  this  stage  of  the  disease.  The  dose  should  be  a  large  one  ; 
and  it  must  be  remembered  that  most  children  have  a  special  tolerance  for 
this  drug,  being  often  able  to  take  it  in  larger  quantities  than  can  be 
readily  borne  by  the  adult.  For  a  child  of  eight  years  old  ten  drops  of 
Fowler's  solution  may  be  given  three  times  a  day,  freely  diluted,  directly 
after  food,  and  every  few  days  the  dose  can  be  increased  by  two  drops. 
The  effect  of  the  medicine  is  to  increase  the  softness  and  mobility  of  the 
glands.     Soon  pain  begins  to  be  complained  of  in  the  swellings,  and  this 


228  DISEASE  IN   CHILDEEJSr. 

is  quickly  followed  by  an  arrest  in  their  growth,  or  even  an  appreciable 
diminution  in  their  size.  Iron  may  be  given  with  the  arsenic  if  thought 
desirable,  and  the  combination  is  preferred  by  some.  Phosphorus  has 
been  also  recommended  as  useful  in  promoting  reduction  ia  size  of  the 
glands  ;  but  this  drug  appears  to  be  decidedly  inferior  to  arsenic.  Iodide 
of  potassium  has  been  found  quite  useless  as  an  absorbent  in  this  disease. 

If  the  patient  come  under  observation  when  the  glandular  swelling  is 
limited  to  the  neck,  and  the  general  system  appears  to  be  unaffected,  we 
may  begin  the  treatment  with  greater  hopes  of  success.  Early  extirpation 
of  the  growths  is  often  advocated,  and  the  operation  is  said  to  have  been 
followed  in  some  cases  by  complete  recovery.  Even  if  this  happy  result 
be  not  attained,  we  may  expect  that  in  a  suitable  case  the  progress  of  the 
disease  wiU  be  sensibly  checked  by  the  operation.  "We  can,  however,  only 
anticipate  good  results  when  the  glandular  enlargement  is  hmited  strictly 
to  one  group  of  glands,  the  spleen  is  unaffected,  and  the  proportion  of  red 
corpuscles  in  the  blood  is  not  greatly  reduced.  Dr.  Gowers  recommends 
that  in  every  case  the  actual  proportion  of  red  corpuscles  be  estimated  by 
the  hsemacytometer,  and  states  that  if  the  proportion  of  coloured  cells  be 
less  than  sixty  per  cent,  of  the  normal  average,  the  idea  of  operating 
should  be  abandoned.  On  the  other  hand,  a  slight  increase  in  the  quan- 
tity of  white  corpuscles  is  not  to  be  considered  prejudicial  to  the  success 
of  the  operation.  After  removal  of  the  swollen  glands  the  child  should  be 
sent  to  a  bracing  seaside  air,  and  arsenic  with  quinine  or  iron  should  be 
given  in  fiill  doses. 

According  to  some  writers,  friction  of  the  growing  glands  with  the 
hand  alone  or  with  some  simple  salve  has  been  found  useful,  and  com- 
pression and  blistering  have  been  also  recommended.  Injections  into  the 
glands  of  varioiis  substances,  such  as  iodine,  carbolic  acid,  etc.,  is  not  a 
safe  method  of  treatment.  In  one  case  in  which  I  injected  tinct.  iodi  into 
a  large  lymphomatous  swelling  the  operation  was  followed  in  a  few  days 
by  a  rapid  and  permanent  increase  in  the  size  of  the  tumour. 


CHAPTER  III. 

ANEMIA. 

Deteeioration  in  the  quality  of  the  blood,  combined  often  with  deficiency 
in  its  quantity,  is  a  common  result  in  infancy  and  childhood  of  any  con- 
dition which  causes  a  temporary  failure  in  the  nutritive  processes.  In  the 
child  ansemia  is  commonly  symptomatic  of  some  discoverable  ill ;  for  the 
obscurer  form,  called  idiopathic  or  pernicious  ansemia  in  the  adult,  is  but 
rarely  met  with  in  early  life. 

The  reason  of  the  exceptional  frequency  of  impoverishment  of  the 
blood  in  childhood  is  not  difficult  of  explanation.  From  the  researches  of 
Denis,  Poggiale,  Wiskemann,  and  others,  it  appears  that  in  infancy  al- 
though the  quantity  of  blood  is  greater  than  it  is  in  maturer  life,  in  propor- 
tion to  the  entire  weight  of  the  body,  this  blood  is  of  lower  specific  gravity, 
and  contains  more  white  corpuscles,  but  less  fibrine  and  soluble  albumen, 
a  smaller  proportion  of  salts,  and  a  considerably  smaller  quantity  of  haemo- 
globin/ With  this  comparatively  dilute  blood  the  growing  child  has  to 
undertake  a  larger  work  than  is  required  from  the  advdt.  He  has  to  sup- 
ply material  for  growth  and  development  instead  of  merely  maintaining 
the  necessary  nutrition  of  tissues  and  organs  already  matured.  The  heart 
and  lungs  are  forced  to  greater  efforts  to  answer  the  demands  made  upon 
them  :  the  first  to  drive  a  sufficient  quantity  of  blood  along  the  relatively 
wider  arterial  channels  ;  the  second  to  aerate  the  larger  proportion  of  blood 
carried  to  them  by  the  more  capacious  pulmonary  artery.  The  lungs  elimi- 
nate carbonic  acid  in  far  higher  proportion  than  is  the  case  in  older  per- 
sons. The  amount  of  urea,  too,  excreted  by  the  kidneys  is  relatively  much 
greater  than  it  is  in  the  adult.  The  work  required  from  the  different  se- 
cretory and  excretory  organs  whose  united  labours  go  to  build  up  the 
growing  frame  may  be  judged  from  the  fact  that  within  twelve  months  of 
its  birth  the  body  has  increased  to  three  times  its  original  weight.  As  Dr. 
Jacoby  has  observed,  the  "  organs  are  in  constant  exertion,  or  rather  over- 
exertion, and  all  this  at  the  expense  of  a  blood  which  contains  less  sohd 
constituents  than  the  blood  of  the  old.  .  Thus  the  natural  oligaemia  of  the 
child  is  in  constant  danger  of  increasing  from  normal  physiological  pro- 
cesses. The  slightest  mishap  reduces  the  equilibrium  between  the  capital 
and  the  labour  to  be  performed,  and  the  chances  for  the  diminution  in  the 
amount  of  blood  in  possession  of  the  child  are  very  frequent  indeed." 

Although  the  blood  of  the  child  is  thus  relatively  poor  as  compared 
with  that  of  the  adult,  a  constant  inflow  of  nutrient  material  enables  it  to 
preserve  a  healthy  standard  and  carrj'  on  its  functions  with  success.     The 


'  HsemogloMn  is  tlie  chief  constituent  of  tlie  red  corpuscles.  In  the  newly  born 
infant  its  amount  is  relatively  larger  than  it  is  in  the  adult,  reaching  the  high  ration  of 
32.3  per  cent,  of  the  whole  solid  constituents  (at  adult  age  it  is  only  18.99  per  cent.). 
This  high  percentage  rapidly  diminishes  until  it  reaches  the  lowest  point  at  the  age  of 
six  months.     It  then  slowly  rises  again. 


230  DISEASE   IN    CHILDEEIN^. 

amoimt  of  food  cousumed  by  the  growing  child  is  far  gi'eater  proportion- 
ately than  that  required  by  the  fully  developed  man.  According  to  Dr. 
Edward  Smith,  the  infant  as  compared  with  the  adult  consumes  three 
times  as  much  carbon  and  six  times  as  much  nitrogen  for  every  pound  of 
his  weight.  If  now,  from  any  cause,  either  from  deficiency  in  the  supply 
of  food,  or  derangement  of  the  machinery  by  which  food  is  elaborated  and 
prepared  for  its  purpose  of  nourishing  and  renewing  the  tissues  the  inflow 
fails,  the  standard  of  the  blood  at  op.ce  sinks  below  the  average  of  health,, 
and  a  state  of  anaemia  or  oligeemia  (poorness  of  blood)  is  induced. 

The  constituents  of  the  blood  v^hich  are  of  the  greatest  importance  iu 
nutrition  are  the  albuminoid  compormds  of  the  plasma  and  the  red  blood 
corpuscles.  The  albuminoid  compounds  constitute  the  material  out  of 
which  the  tissues  are  noiuished  ;  the  hssmoglobin  of  the  red  corpuscles 
carries  the  oxygen,  without  which  the  chemical  changes  necessary  for  nu- 
trition are  impossible.  In  angemia  the  blood  is  impoverished  in  its  Eubu- 
minous  constituents,  es]3ecially  in  its  hgemogiobui.  Therefore,  as  the 
amount  of  iron  is  in  direct  proportion  to  the  amount  of  haemoglobin,  a 
diminution  in  the  latter  means  a  deficiency  in  the  former  ;  and  as  the  chief 
of&ce  of  the  haemoglobin  is  that  of  conveying  oxygen  to  the  tissues,  the 
blood  iu  anaemia  is  no  longer  able  efficiently  to  perform  its  respiratory  and 
nutritive  functions. 

■  Causation. — In  early  life  any  cause  which  interferes  with  the  orderly 
renewal  of  the -normal  constituents  of  the  blood  leads  to  anaemia.  In  the 
infant — a  being  who  is  dependent  for  health  upon  a  full  daily  supply  of 
food — not  only  serious  disease  but  even  the  most  simple  acute  derange- 
ment will  leave  the  blood  in  a  state  of  temporary  oligaemia.  This  is 
usually  rapidly  recovered  from,  for  in  the  healthy  child  convalescence  is. 
short,  and  the  nutritive  functions  quickly  resume  their  course  when  the 
obstacle  to  their  proper  exercise  has  disappeared.  By  ansemia,  however, 
is  usually  meant  a  more  jprolonged  poorness  of  the  blood — a  condition  in 
which  the  symptoms  of  general  debility  are  alhed  vdth  others  indicating 
an  imperfect  performance  of  the  bodily  functions. 

The  causes  of  such  a  condition  maybe  divided  into  two  classes,  accord- 
ing as  to  whether  they  interfere  with  the  continued  renovation  of  the  blood 
or  abnormally  increase  its  consumption. 

In  the  first  class  are  included  all  the  various  conditions  which  hinder 
the  introduction  and  elaboration  of  nutritive  material.  Thus,  actual  defi- 
ciency of  food,  such  as  arises  from  extreme  poverty  or  wilful  neglect ;  an 
unsuitable  diet,  the  stomach  being  loaded  with  food  which,  from  its  nature 
or  form,  is  beyond  the  child's  power  of  digestion  ;  functional  derangements 
of  the  gastro-intestinal  canal,  owmg  to  w^hich  an  otherwise  suitable  food 
is  rendered  temporarily  inapproj)riate — these  causes  may  prevail  at  all 
periods  of  childhood,  but  are  especially  frequent  during  the  period  of 
infancy  ;  and  the  antemia  and  wasting  which  are  so  common  in  hand-fed 
babies  can  usually  be  referred  to  the  action  of  these  agencies.  To  them 
must  be  added  the  influence  of  imperfect  ventilation.  Oxygen  is  as  essen- 
tial to  healthy  tissue  change  as  are  the  elements  of  food  themselves,  and  in 
its  absence  the  chemical  changes  necessary  for  the  renewal  and  develop- 
ment of  the  tissues  are  impossible.  Consequently  infants  confined  to 
close,  ill-ventilated  rooms  are  pale  and  flabby,  however  carefully  their 
dietary  may  be  adjusted. 

The  above  causes  are  also  powerful  to  impede  nutrition  and  promote 
the  impoverishment  of  the  blood  after  the  period  of  infancy  has  gone  by. 
The  influence  of  digestive  derangements,  combined  or  not  with  want  of 


ANJSMIA — CAUSATION — MORBID   ANATOMY.  231 

fresli  air  and  exercise,  is  one  of  the  commonest  causes  of  anaemia  in  later 
childliood.  The  causes  which  induce  impoverishment  of  the  blood  are  no 
doubt  often  complex  ;  but  of  such  as  act  alone  imperfect  digestion  from 
catarrh  of  the  stomach  is  perhaps  to  be  blamed  more  often  than  any  other 
injurious  condition.  These  attacks  tend  to  be  repeated,  and,  as  is  else- 
where explained,  recurring  gastric  catarrh  may  induce  a  degree  of  pallor 
and  wasting  which  excites  the  greatest  alarm  in  the  minds  of  the  parents, 
and  often  requires  very  careful  treatment  for  its  prevention  and  cure  (see 
Gastric  Catarrh). 

Again,  the  diathetic  diseases — tuberculosis,  scrofula,  and  syphilis — 
often  induce  a  degree  of  anaemia,  even  before  any  local  manifestations  of 
the  constitutional  disposition  are  discoverable.  In  syphilis,  also,  the  dis- 
ease, after  apparent  recovery,  is  apt  to  leave  behind  it  a  state  of  profound 
anaemia,  which  in  many  cases  is  to  be  attributed,  not  to'  the  malady,  but  to 
the  medication  to  which  the  patient  has  been  subjected ;  for  a  prolonged 
course  of  mercury  is  an  unfailing  cause  of  impoverishment  of  the  blood. 
In  rickets,  the  beginning  of  the  disease  is  announced,  and  its  progress 
accompanied,  by  a  marked  degree  of  annsmia,  which  indicates  the  unfit- 
ness of  the  blood  in  such  a  case  to  fulfil  all  the  requirements  of  healthy 
nutrition.  Of  other  special  general  diseases  which  may  lead  to  diminution 
in  the  amount  of  haemoglobin  and  so  set  up  anaemia  may  be  mentioned 
rheumatism,  scurvy,  and  the  cachectic  condition  induced  by  malaria. 

Disease  of  special  organs  concerned  in  sanguification — the  spleen,  the 
lymphatic  system,  etc. — is,  of  course,  followed  by  great  alteration  in  the 
quality  of  the  blood.  In  extensive  amyloid  degeneration  of  these  organs, 
the  marked  pallor  of  the  patient  is  one  of  the  most  striking  symptoms  of 
the  disease  ;  and  in  lymphadenoma  the  patient  is  peculiarly  pale  and 
bloodless. 

The  causes  which  increase  the  consumption  of  the  blood  are  :  Profuse 
haemorrhages,  as  in  melana  neonatorum,  haemophilia  and  hamiorrhagic 
purpura  ;  severe  diarrhoea  ;  chronic  j)ui'ulent  discharges,  as  in  cases  of 
chronic  empyema  with  a  fistulous  opening  in  the  chest-wall ;  cirrhosis  of 
lung  with  dilatation  of  bronchi ;  albuminuria  ;  onanism  ;  etc.  In  this 
class,  too,  must  be  included  rapid  growth,  which  is  a  ver^'  frequent  source 
of  languor  and  anaemia.  It  must  be  remembered,  however,  that  at  the 
age  when  growth  is  apt  to  be  most  rapid  the  child  is  often  exposed  to 
other  infiueuces  which  may  also  tend  to  set  up  impoverishment  of  the 
blood,  such  as  confinement  to  close  rooms  and  want  of  exercise. 

Idiopathic  anaemia  (which  is  sometimes  seen  in  young  people)  may  re- 
sult from  bad'  and  insufficient  food  or  other  depressing  cause  acting  upon 
the  general  system  ;  sometimes  it  is  the  consequence  of  mental  shock,  as  in 
the  case  of  a  boy  who  was  under  the  care  of  Sir  William  Gull,  in  Guy's 
Hospital.  The  lad  began  to  suffer  shortly  after  being  attacked  by  a  num- 
ber of  sheep  in  a  field. 

Morbid  Anatomy. — In  anaemia  the  blood  may  be  merely  deficient  in 
amount  (oligaemia),  but  it  is  usually  found  that  there  is  also  a  deficiency  in 
the  haemoglobin  (aglobulosis).  It  is  not  often  that  actual  diminution  in  the 
number  of  the  red  corpuscles  occurs  in  ordinary  symptomatic  anaemia  un- 
less, indeed,  the  impoverishment  result  from  severe  haemorrhage  ;  but 
these  bodies  are  said  to  be  considerably  reduced  in  size,  and  in  certain 
forms  of  anaemia  it  is  common  to  find  many  corpuscles  with  a  diameter 
greatly  below  the  average.  The  blood  is  paler  than  natural,  for  in  con- 
sequence of  the  decrease  in  the  h;emogiobin  it  is  deficient  in  iron.  Its 
specific  gravity  is  also  lower,  and  it  coagulates  slowly  into  a  loose  clot. 


232  DISEASE  iisr  childeen. 

As  a  result  of  tlie  imperfect  nutrition  of  the  tissues  whicli  is  the  con- 
sequence of  the  deteriorated  quahty  of  the  circulating  fluid,  a  degree  of 
fatty  degeneration  may  be  found  in  the  heart,  the  liver,  the  kidnej's,  and 
even  in  the  walls  of  the  blood-vessels  ;  also  in  the  voluntary  muscles,  and 
the  glands  of  the  stomach  and  intestmes. 

In  idiopathic  ansemia  fatty  degeneration  of  organs  is  also  commonly 
observed.  There  are,  moreover,  ecchymoses  of  serous  membranes,  the  re- 
tina, etc.  The  blood  is  not  only  diminished  in  quantity,  but  the  red 
blood  corpuscles  are  also  greatly  reduced  in  number,  being,  according  to 
M.  Lepine,  one-fourth,  one-sixth,  or  even  one-tenth  of,  their  normal  pro- 
portions. The  white  corpuscles  are  not  more  numerous  than  natural,  at 
least  they  are  not  increased  to  anything  like  the  degree  observed  in  leu- 
khsemia.  In  some  cases  of  pernicious  ansemia  minute  red  corpuscles  have 
been  noticed  measuring  only  one-fourth  of  their  natural  size,  and  wanting  ' 
the  characteristic  bi-conate  shape.  These  bodies,  however,  appear  not  to 
be  present  in  every  case. 

Symptoms. — Poorness  of  the  blood  implies  an  imperfect  state  of  the 
general  nutrition.  This  is  especially  the  case  in  young  subjects  whose 
blood,  as  has  been  already  explained,  can  only  carry  on  its  functions  effi- 
ciently on  the  condition  that  it  is  continually  reinforced  by  a  regular  inflow 
of  projDerly  elaborated  nutritive  material.  Consequently,  in  addition  to  a 
general  pallor,  the  muscles  of  such  subjects  are  small  and  flabby,  their 
strength  is  reduced,  and  then-  spirits  may  perhaps  be  depressed.  Lang-uor 
and  indisposition  to  exercise  are  not,  however,  constant  symptoms  of 
ansemia  in  childhood.  Boys  suffer  in  this  respect  much  less  than  girls, 
and  when  free  from  actual  pain  or  discomfort  such  patients  are  often 
lively,  and  join  with  as  much  alacrity  in  boisterous  games  as  if  they  were 
perfectly  well.  Indeed,  this  cheerfulness  and  activity  may  in  some  cases 
be  an  important  aid  to  diagnosis  (see  Tuberculosis). 

The  tint  of  the  skin  may  be  a  clear,  transparent  whiteness.  Often, 
however,  it  is  dull  and  pasty  ;  or  may  have  a  faint  greenish  cast  similar  to 
the  hue  of  chlorosis,  and  the  lower  eyehd  may  be  Hvid  and  purplish.  The 
mucous  membranes  are  also  pallid.  Coldness  of  the  extremities  is  a 
familiar  feature  of  this  condition.  In  anaemic  little  girls  we  are  often  told 
that  the  feet  and  legs  are  never  warm,  and  the  hands  feel  cold  and  clammy 
to  the  touch.  Slight  oedema  is  often  met  with.  It  may  affect  the  lower 
eyelid,  but  less  commonly  than  in  the  adult.  Usually  it  is  noticed  in  the 
feet  and  ankles,  and  if  the  ansemia  be  great,  may  involve  also  the  hands 
and  arms.     In  rare  cases  there  may  be  moderate  ascites. 

Breathlessness  and  palpitation  on  slight  exertion  sufficiently  pronounced 
to  cause  distress  are  not  common  symptoms  of  ansemia  in  the  child,  but 
they  are  sometimes  present.  The  appetite  is  often  poor,  discomfort  may 
be  complained  of  after  food,  and  the  bowels  are  usually  confined.  As  this 
condition  of  the  blood  is  in  many  cases  a  consequence  of  gastric  derange- 
ment, all  the  symptoms  which  are  elsewhere  enumerated  under  the  head- 
ing of  gastric  catarrh  are  often  to  be  noticed.  Flatulence,  especially,  is  a 
common  phenomenon,  and  faintness  or  actual  sjmcojje  may  occur  from 
pressure  upwards  against  the  heart  of  a  suddenly  distended  colon.  The 
temperatm-e  is  seldom  elevated  in  an  uncomplicated  case  of  simple  ansemia. 
Pyrexia  may,  however,  be  present  as  a  consequence  of  the  cause  to  which 
the  impoverishment  of  the  blood  is  owing,  or  to  some  accidental  comphca- 
tion,  such  as  teething,  catarrh,  etc. 

Children,  the  subjects  of  ansemia,  are  usually  very  nervous  and  excit- 
able, and  on  examination  of  the  chest  we  often  find  the  heart  acting  violently, 


ANJEMIA — SYMPTOMS — DIAGNOSIS.  233 

can  notice  a  strong  pulsation  in  the  neck,  and  with  the  hand  placed  upon 
the  prsecordial  region  can  feel  a  well-marked  systolic  thrill.  As  the  violence 
of  the  cardiac  action  subsides  the  thrill  ceases,  and  the  carotid  pulsations 
diminish  or  disappear.  The  sounds  may  then  be  heard  to  be  ill-accen- 
tuated, or  perhaps  murmurish.  Although  anaemic  cardiac  murmurs  are 
said  to  be  uncommon  in  young  subjects,  it  is  not  rare  in  cases  of  pro- 
nounced ansemia  to  detect  a  murmur  which  ceases  to  be  heard  as  the 
patient  improves.  The  murmur  may  be  at  the  apex  of  the  heart  and  is — 
sometimes  at  least — accompanied  by  displacement  of  the  apex-beat  upwards 
and  to  the  left,  as  if  from  dilatation  of  the  left  ventricle.  Basic  murmurs 
are,  however,  the  more  common  phenomena.  At  the  base  of  the  heart  the 
least  pressure  upon  the  pulmonary  artery  from  enlarged  bronchial  glands 
will  give  rise  to  a  loud  systohc  murmur  in  that  vessel.  In  many  cases  we 
can  hear  a  venous  hum  in  the  jugular  vein  in  the  neck,  sometimes,  also,  in 
the  left  innominate  vein,  behind  the  upper  part  of  the  sternum. 

Bleeding  from  the  nose  and  gums  is  not  rare  in  anaemic  children  ;  and 
in  hospital  patients  petechise  are  common  in  the  skin  as  the  result  of  flea- 
bites.  From  this  cause  the  bodies  of  poor  children  are  often  speckled  all 
over  with  little  extravasations  of  blood. 

Pain  across  the  forehead,  or  sometimes  at  the  back  of  the  head,  is  often 
complained  of.  In  infants  more  serious  symptoms  ma^y  be  met  with  as  a 
consequence  of  ansemia  of  the  brain.  The  child  Hes  with  a  pale  shrunken 
face,  eyelids  only  partially  closed,  and  fontanelle  depressed.  His  extrem- 
ities feel  cold,  and  a  thermometer  in  the  rectum  registers  a  temperature 
below  the  normal  level.  Soon  the  infant  sinks  into  a  state  of  semi-stupor, 
and  unless  aroused  by  energetic  stimulation  will  probably  die.  Impover- 
ishment of  blood  and  prostration  so  profomid  are  apt  to  be  complicated  by 
thrombosis  of  the  cerebral  sinuses  or  collapse  of  the  lung. 

The  duration  of  a  case  of  ordinary  simple  anaemia  varies  according  to 
the  measures  which  may  be  taken  to  remove  the  cause  or  causes  which  are 
impeding  the  supply  of  nutritive  material  to  the  blood.  If  the  cause  can 
be  removed,  and  the  child  be  afterwards  fed  with  judgment  and  placed 
under  good  sanitary  conditions,  recovery  usually  follows  very  quickly. 

In  idiopathic  ancemia  all  the  preceding  symptoms  may  be  noted.  In 
this  form  of  the  disease  the  anaemia  is  more  profound.  The  skin  is  of  the 
colour  of  ivory  and  the  mucous  membranes  seem  perfectly  bloodless.  Optic 
neuritis  may  occur  with  haemorrhage  into  the  retina.  Epistaxis  is  common, 
and  vomiting  may  be  frequent  and  distressing.  The  child  becomes  exces- 
sively feeble,  and  has  irregular  attacks  of  pyrexia  in  which  the  temperature 
rises  to  103°  or  104°.  Towards  the  end  of  the  disease,  however,  elevation 
of  temperature  ceases  to  be  noticed  ;  indeed,  the  bodily  heat  usually  falls 
to  a  subnormal  level.     The  blood  has  the  characters  already  described. 

Diagnosis. — In  every  case  of  anaemia  it  is  important  with  regard  to 
prognosis  and  treatment  that  we  should  exclude  serious  organic  an^ 
diathetic  disease.  The  diagnosis  of  the  many  conditions  which  induce 
impoverishment  of  the  blood  is  treated  of  under  their  several  headings. 
It  may  be  only  stated  generally  that  if  the  cause  lie  elsewhere  than  in  some 
obvious  derangement  of  the  digestion,  we  should  institute  very  searching 
inquiry  into  the  family  and  special  history  of  the  patient,  particularly  with 
regard  to  diathetic  tendencies,  and  should  make  careful  examination  of 
the  various  organs. 

Idiopathic  anaemia  may  be  distinguished  by  the  profound  deterioration 
of  the  blood  without  increase  in  the  white  corpuscles  ;  the  absence  of  dis- 
coverable cause  for  the  pallor  and  weakness  ;  and  the  attacks  of  irregvdar 


234  DISEASE   IN"   CHILDEEISr. 

pyrexia.  Leticocytlieinia  is  cliaracterised  by  increase  in  the  proportion  of 
white  corpuscles,  and  by  enlargement  of  the  spleen  or  lymphatic  glands. 

Prognosis. — In  ansemia  the  prognosis  depends  very  much  upon  the 
primary  disease,  if  any  such  can  be  discovered.  If  the  poorness  of  blood 
be  the  sequel  of  some  previous  acute  illness,  or  other  cause  M^hich  has 
ceased  to  prevail,  the  patient  usually  responds  well  to  treatment  and 
quickly  recovers  under  ordinary  restorative  measures.  In  cases  of  idio- 
pathic anaemia,  when  the  prostration  is  great,  the  pallor  extreme,  and  the 
temperature  high,  the  child's  prospects  are  very  unfavourable. 

Treatment. — Anaemia  must  be  treated  according  to  the  cause  which 
has  produced  it.  Impaired  nutrition  and  a  pallid  face  form  in  themselves 
no  necessary  indication  for  the  emjDloyment  of  chalybeate  remedies.  The 
commonest  cause  of  anaemia  in  the  child,  as  has  akeady  been  stated,  is 
gastro-intestinal  derangement.  In  such  a  case  iron  has  no  power  to  im- 
prove the  condition  of  the  blood  until  the  hindrance  to  digestion  has  been 
removed.  In  anaemic  infants  the  dietary  must  be  reconstructed  upon  the 
principles  recommended  elsewhere  (see  Infantile  Atrophy).  In  older 
children  if,  as  often  haj)pens,  the  patient  be  suffering  from  rej)eated  attacks 
of  gastric  catarrh  more  or  less  severe,  the  digestive  disturbance  must 
receive  careful  treatment,  and  measures  must  be  adopted  to  lessen  the 
child's  suscejDtibility  to  changes  of  temperature  and  to  protect  his  sensi- 
tive body  from  the  cold  (see  Gastric  Catarrh).  In  all  cases  plenty  of  fresh 
air  should  be  prescribed.  The  parents  should  be  warned  of  the  necessity 
of  thorough  ventilation  of  nurseries  and  sleeping-rooms,  and  the  child  must 
be  sent  out  as  much  as  possible  into  the  open  air.  It  is  important,  ho^f- 
ever,  not  to  force  the  patient  to  take  exercise  when  his  feeble  powers  will 
not  admit  of  his  deriving  benefit  from  muscular  activity.  If  his  weakness 
be  great,  the  child  should  go  out  only  in  a  carriage  ;  and  when  in-doors 
care  should  be  taken  that  his  wearied  muscles  are  allowed  a  sufficiency  of 
needful  rest.  As  he  mends,  however,  he  should  be  urged  more  and  more 
to  exert  himself,  and  in  severe  cases  a  desire  for  exercise  is  a  valuable 
sign  of  improvement. 

The  child  must  take  plenty  of  nitrogenous  food,  and  if,  as  sometimes 
happens,  the  appetite  is  poor,  with  a  special  dislike  to  meat,  his  fancies 
must  be  consulted  in  every  way  possible.  Often  a  child  will  eat  a  small 
bird,  as  a  lark  or  a  snipe,  when  he  turns  with  disgust  from  beef  and 
mutton.  Pounded  underdone  meat  spread  upon  bread  and  butter  will 
often  be  taken,  or  the  meat  may  be  diffused  through  a  meat  jelly.  Eggs, 
milk,  and  fish  are  aU  of  service,  and  a  moderate  quantity  of  farinaceous 
food  may  be  allowed  ;  but  the  child  must  be  prevented  from  taking  starchy 
matters  to  the  exclusion  of  more  nutritious  articles  of  diet.  When  the 
appetite  is  poor,  it  may  be  often  improved  by  taking  three  times  a  day  a 
drop  or  two  drops  of  the  dilute  hydrocyanic  acid  (P.  B.)  with  five  grains 
of  bicarbonate  of  soda  in  infusion  of  orange  peel.  The  draught  can  be 
sweetened  with  spirits  of  chloroform,  and  should  be  taken  an  hour  before 
meals. 

Iron  is  only  to  be  resorted  to  as  an  addition  to  the  more  general  meas- 
ures for  restoring  nutrition  and  improving  digestive  power,  and  it  must 
not  be  given  until  the  disorder  of  the  gastric  functions  has  been  attended 
to.  Iron  acts  far  more  energetically^  when  it  is  combined  with  aperients. 
Often,  indeed,  until  the  bowels  have  been  weU  relieved  by  approj)riate 
purgation  the  remedy  seems  to  be  perfectly  inert.  Not  seldom,  after  giv- 
ing an  iron  mixture  perseveringly  for  a  length  of  time  without  any  sign  of 
improvement,  I  have  noticed  an  immediate  alteration  for  the  better  when 


ANEMIA — PEOGlSrOSTS — TEEATMENT.  235 

the  chalybeate  has  been  exchanged  for  a  morning  and  evening  dose  of  the 
compound  senna  mixture  of  the  British  Pharmacopoeia.  The  form  in  which 
the  iron  is  given  is  of  httle  importance.  The  dose  should  always  be  as 
large  a  one  as  the  child  can  bear  without  discomfort ;  and  if  the  digestion 
be  in  good  order,  the  acid  preparations  are  to  be  preferred  as  a  rule  to  the 
alkaline  salts.  Still,  if  there  be  any  remains  of  catarrh  of  the  stomach,  the 
ammonio-citrate  should  be  given  with  an  alkali.  Most  children  bear  the 
sulphate  of  iron  well.  For  a  child  of  six  years  old,  five  grains  of  the  dried 
salt  may  be  given  in  a  teaspoonful  of  glycerine  three  times  a  day  directly 
after  food.  This  dose  may  seem  rather  a  large  one,  but  it  is  rare  to  find 
any  signs  of  ii'ritation  produced  by  the  medicine,  and  the  tonic  effect  upon 
the  system  is  usually  rapid  and  decided.  The  perchloride  is  also  a  good 
form  for  administration  of  the  remedy.  Twenty  to  thirty  drops,  well  di- 
luted with  water  and  sweetened  with  glycerine,  may  be  taken  after  each 
meal.  These  preparations  are  far  more  useful  than  the  various  iron  syi'ups 
which  are  commonly,  preferred.  I  have  seen  many  a  case  of  anasmia  aris- 
ing from  gastric  catarrh  prolonged  by  the  use  of  these  syrups,  which 
promote  acidity  and  flatulence  and  encourage  the  excessive  secretion  of 
mucus. 

In  some  children  almost  all  forms  of  iron  seem  to  act  as  direct  irritants 
to  the  stomach,  inducing  mdigestion  and  peevishness  of  temper  and  caus- 
ing wakefulness  at  night.  In  these  cases  the  dialysed  iron  is  the  best 
form  in  which  the  remedy  can  be  administered.  Pure  chalybeate  waters 
are  also  of  service  if  the  child  can  be  induced  to  take  them.  Their  value 
is,  no  doubt,  enhanced  by  the  fi'esh  country  air  and  exercise  by  which  the 
change  to  a  chalybeate  spring  is  usually  accompanied. 

Under  the  use  of  iron  the  red  corpuscles  increase  in  size  and  the  pro- 
portion of  haemoglobin  is  therefore  largely  augmented.  The  imjDrovement 
is  announced  by  a  healthier  tint  in  the  complexion,  an  improvement  in  the 
appetite,  and,  if  the  child  had  been  previously  listless  and  dull,  by  greater 
freedom  and  sprightliness  in  his  movements. 

Arsenic  is  another  remedy  of  great  value  in  improving  the  condition  of 
the  blood.  Children  bear  arsenic  well.  The  drug,  unless  given  in  very 
large  quantities,  is  rarely  a  cause  of  gastric  irritation.  In  fact,  as  is  well 
known,  arsenic  in  small  doses  is  a  valuable  sedative  to  the  digestive  organs 
and  often  arrests  vomiting.  As  a  tonic  the  remedy  should  be  given  to  a 
child  of  six  years  old  in  the  dose  of  three  or  four  minims  of  Fowler's  solu- 
tion directly  after  food.  When  the  digestion  is  greatly  impaired  by  re- 
peated attacks  of  gastric  catarrh  the  effect  of  this  medication  is  often  very 
striking.  The  arsenic  may  be  usefully  combined  with  a  drop  or  two  of  the 
tincture  of  nux  vomica.  Another  remedy  from  which  good  results  have 
been  obtained  is  phosphorus.  This  powerful  drug  may  be  safely  given  to 
a  child  of  six  years  old  in  doses  of  yl-y  to  y^  of  a  grain,  I  have,  however, 
no  personal  experience  of  its  value. 

Cod-liver  oil  is  of  service  as  an  additional  food,  and  in  combination 
with  iron  wine  is  a  favoui'ite  remedy  in  all  forms  of  anaemia  in  young  sub- 
jects. The  alcohol  of  the  vinum  ferri  is  no  doubt  a  valuable  therapeutic 
agent.  Alcoholic  stimulants  taken  with  food  help  to  promote  digestion, 
and  in  many  pallid,  weakly  children  have  great  virtue  in  aiding  the  return 
to  health.  Sound  claret,  or  the  St.  Raphael  tannin  wine,  diluted  with  an 
equal  proportion  of  water,  is  usually  taken  readily  by  the  child,  and  is  a 
sensible  help  to  other  treatment. 

Cold-water  packing  is  said  to  be  useful  in  improving  the  condition  of 
the  blood.     Drs.    M.  P.   Jacoby  and  V.  White  have  reported  a  series  of 


236  DISEASE  IN   CHILDEEIs". 

cases  in  which  ansemia  was  treated  by  the  regular  application  of  the  cold 
pack  followed  by  massage.  The  patient  was  enveloped  in  a  cold  wet  sheet, 
this  was  covered  by  a  drier  sheet,  and  over  all  six  blankets  were  laid  and 
carefully  tucked  in.  After  the  lapse  of  an  horn-  the  coverings  were  re- 
moved and  the  skin  and  muscles  were  vigorously  shampooed.  This  plan 
of  treatment  was  combined  with  rest  and  careful  feeding,  and  was  attended 
by  very  good  results.  It  might  be  employed  mth  advantage  in  the  case  of 
weakly,  pallid  children  in  whom  anorexia  is  a  marked  feature,  for  one  of 
its  most  pronounced  effects  was  found  to  be  an  immediate  improvement  in 
the  appetite.  The  induction  of  sleepiness  by  the  pack  and  massage  is 
usually  an  indication  that  the  patient  is  benefiting  by  the  treatment. 


CHAPTER  lY. 

ENLARGEMENT  OF  THE  SPLEEN. 

Enlaegeivient  of  the  spleen  is  common  in  early  life,  and  is  found  in  the 
course  of  a  variety  of  diseases. .  The  symptom  is  alluded  to  incidentally  in 
the  descriptions  of  the  various  forms  of  illness  in  which  the  phenomenon 
occurs  ;  but  the  subject  is  of  sufficient  importance  in  a  chnical  point  of 
view  to  deserve  a  special  chapter  for  its  consideration. 

A  splenic  tumour  may  be  of  acute  or  chronic  growth.  Acute  enlarge- 
ment is  seen  in  typhoid  fever  and  ague,  sometimes  in  acute  tuberculosis,  and, 
it  is  said,  in  cerebro-spinal  fever  ;  also  the  enlarged  spleen  found  in  cases  of 
leucocythemia  may  be  included  in  this  class,  for  in  early  life  leukh^emia 
often  runs  an  acute  course.  Rapid  increase  in  size  of  the  organ  is  also  oc- 
casionally met  with  as  a  result  5f  splenic  embolism  in  the  course  of  ulcera- 
tive endocarditis. 

Chronic  enlargement  of  the  spleen  may  be  the  consequence,  and  some- 
times the  only  manifestation,  of  the  cachectic  condition  induced  by  mala- 
rious poison.  It  occiu's  in  some  cases  of  amyloid  degeneration,  although 
a  sjDleen  so  affected  is  not  always  increased  in  size.  It  is  a  common  symp- 
tom of  lymphadenoma,  is  not  unfrequently  a  consequence  of  atrophic 
cirrhosis  of  the  hver,  and  may  be  met  with  in  cases  of  old-standing  dis- 
ease of  the  heart.  Lastly,  it  may  be  due  to  a  simple  hyperj)lasia.  Hj-per- 
trophy  of  the  spleen  may  occur  in  rickets  and  syj)hilis,  especially  the  latter  ; 
but  is  also  found  in  cases  where  syphilis  may  be  positively  excluded,  and 
in  cases,  too,  where  there  is  no  reason  to  suspect  any  malarious  origin  of 
the  swelling. 

In  the  child  a  spleen  is  not  necessarily  diseased  because  its  lower  edge 
is  within  reach  of  the  finger.  The  healthy  organ  is  sometimes  pushed  down, 
so  as  to  be  felt.  This  displacement  may  occur  in  cases  of  copious  effusion 
into  the  left  pleura,  and  is  common  in  rickets  where  there  is  much  retrac- 
tion of  the  ribs. 

In  determining  the  existence  of  enlargement  of  the  spleen  it  is  not  suf- 
ficient merely  to  ascertain  the  position  of  the  lower  edge  ;  for  considerable 
swelling  of  the  organ  may  be  present  although  its  inferior  border  does  not 
project  below  the  margin  of  the  ribs.  In  the  child  the  spleen  often  extends 
backwards  and  upwards  as  well  as  downwards,  and  may  reach  posteriorly  to 
the  spinal  column.  By  percussion  in  such  cases  we  can  often  detect  dulness 
in  the  axilla  reaching  upwards  as  far  as  the  fourth  or  fifth  rib,  and  in  the 
back  extending  as  far  upwards  as  the  infei-ior  angle  of  the  scapula.  In  all 
cases  where  a  sj)lenic  tumour  is  suspected  the  size  of  the  organ  should  be 
estimated  by  percussion  as  well  as  palpation.  When  the  lower  part  of  the 
organ  projects  below  the  ribs  into  the  abdomen  it  is  easily  felt  by  laymg  the 
hand  flat  upon  the  belly  and  pressing  gently  with  the  finger  tips.  That 
the  swelhng  thus  discovered  is  due  to  increase  in  size  of  the  spleen  is  indi- 
cated by  the  superficial  position  of  the  tumour,  by  the  comparative  thinness 


238  DISEASE  I]S"   CHILDEEN. 

of  its  inner  border,  and  by  the  notch  which  can  often  be  distinctly  perceived 
by  the  finger. 

An  enlarged  spleen  is  usually  firm  and  resisting  to  the  touch,  especially 
if  the  enlargement  is  a  chronic  process.  In  t;}'phoid  fever,  however,  the 
substance  of  the  swollen  organ  is  unusually  soft,  and  on  this  account  can 
sometimes  be  only  felt  by  a  practised  finger.  In  acute  forms  of  swelling 
the  increase  in  size  is  accomjDanied  by  some  tenderness  on  jjressui-e.  In 
chronic  enlargements  there  may  be  also  tenderness,  but  this  is  commonly 
due  in  such  cases  to  the  presence  of  local  peritonitis. 

In  the  present  chapter  it  will  be  unnecessary  to  refer  again  to  all  the 
forms  of  splenic  tumour  met  with  in  the  child.  It  wiU  be  sufficient  to  con- 
sider the  chronic  enlargement  which  occurs  as  a  consequence  of  a  simple 
h;5^erplasia  of  the  organ. 

Simple  Hyperplasia  of  the  spleen  is  a  not  uncommon  condition  in  in- 
fancy and  early  childhood.  Often  the  patient  may  bear  traces  of  inherited 
S57)hilis  or  show  some  symptoms  of  rickets  ;  but  this  is  not  always  the  case, 
and  sometimes  no  sign  of  diathetic  disease  or  constitutional  weakness  is 
anywhere  to  be  detected.  When  the  enlargement  is  thus  present  in  a  child 
of  apparently  healthy  constitution  its  etiology  is  difficult  to  estabHsh.  In 
some  of  the  cases  which  have  come  under  my  notice  the  enlargement  has 
been  preceded  by  gastro-intestinal  derangement.  In  others  the  child  has 
been  subject  to  fi-equent  attacks  of  pulmonary  catarrh.  Sometimes  the 
sj)lenic  tumour  was  first  discovered  shortly  after  an  attack  of  measles ;  but 
it  is  difficult  to  admit  a  connection  between  these  derangements  and  the 
splenic  hyperplasia. 

Morbid  Anatomy. — When  enlarged  from  simple  hypertrophy  the  spleen 
retains  its  normal  shape.  It  is  firm  and  smooth  ;  its  cajosule  is  thickened  ; 
and  a  section  shows  a  j)ale  red  or  reddish  purple  siu'face,  with  the  Malpighian 
bodies  more  or  less  distinctly  visible. 

Symptoms. — The  existence  of  enlargement  of  the  spleen  is  at  once  in- 
dicated by  the  complexion  of  the  child.  The  whole  body — both  skin  and 
mucous  membranes — is  pale  and  bloodless  ;  but  the  tint  of  the  face  is 
characteristic.  It  has  something  of  the  colour  of  ivory  or  wax,  with  the 
addition  of  a  faint  olive  cast  which  is  not  found  in  either  of  these  substances. 
Often  we  notice  a  curious  transparency,  especially  about  the  mouth  and 
eyelids.  The  belly  is  large  and  the  spleen  can  be  readity  felt  as  a  smooth, 
firm  mass.  If  the  increase  in  size  is  great,  the  tumour  projects  diagonally 
across  the  abdomen,  and  presents  on  its  inner  surface  the  abrupt  edge 
broken  towards  the  middle  by  the  notch.  Usually  the  organ  projects  up- 
wards and  to  the  back  as  well  as  downwards,  and  its  limits  in  these  du-ec- 
tions  can  be  estimated  by  percussion.  Sometimes  it  is  fi'eely  movable  by 
the  hands,  and  it  always  descends  when  a  deep  breath  is  taken,  rising  again 
in  expiration. 

Although  pale  and  bloodless  the  child  has  often  a  considerable  amount 
of  flesh,  and  is  greatly  wasted  only  in  exceptional  cases.  He  is,  however, 
weak  and  languid.  The  bowels  are  often  irritable,  and  in  children  of  three 
or  four  years  old  the  appetite  is  capricious  and  jDerhaps  peiwerted,  so  that 
the  patient  shows  a  curious  tendency  to  eat  cinders,  chalk,  slate-pencil, 
and  other  gritty  or  even  disgusting  substances.  (Edema  of  the  lower 
limbs  and  eyelids  is  sometimes  noticed,  and  petechiee  and  bruise-like 
j)atches  may  be  present  in  the  skin.  There  is  also  a  marked  tendency  to 
epistaxis. 

On  examination  of  the  blood,  the  red  corpuscles  form  rouleaux  in  the 
usual  manner  ;  but  tested  by  the  hsemacytometer  thek  number  is  foimd 


ENLAKGEMENT   OF   THE   SPLEET^ — SYMPTOMS.  239 

to  be  reduced  considerably  below  the  normal  average,  and  the  white  cells 
are  often  appreciably  increased,  although  seldom  to  the  degree  observed 
in  cases  of  leucocythemia.  Sometimes  both  red  and  white  corpuscles  are 
irregular  in  shape. 

A  little  boy,  aged  one  year  and  seven  months,  was  said  to  have  been 
boi-n  strong  and  healthy.  He  was  the  youngest  of  four,  his  elders  being 
all  strong  and  well.  He  did  not  snuffle  after  birth,  nor  were  any  spots 
noticed  at  that  time  on  the  buttocks.  Until  the  age  of  ten  months  the 
child  excited  no  anxiety,  but  he  then  began  to  get  pale  and  to  lose  flesh. 
He  had  been  lately  very  restless  at  night. 

On  examination  the  infant  was  seen  to  be  very  anaemic  over  the  whole 
body,  and  his  complexion  was  of  a  dull  yellowish-white,  especially  on  the 
cheeks.  He  was  thin  although  not  emaciated,  and  his  expression  shoAved 
BO  sign  of  distress.  The  child  was  the  subject  of  slight  rickets,  he  had 
only  two  teeth,  his  chest  was  a  little  flattened  laterally,  and  there  was  in- 
significant enlargement  of  the  epiphyses  of  the  long  bones.  His  legs  were 
small,  and  he  had  never  been  able  to  walk.  The  fontanelle  was  about  half 
an  inch  in  diameter.  The  frontal  bone  was  rather  prominent  on  each  side 
of  the  middle  line,  and  there  was  some  inconsiderable  thickening  of  the 
parietal  bones.     Cranio-tabes  was  well  marked. 

The  belly  was  very  full  and  prominent,  especially  on  the  left  side.  As 
the  child  lay  on  his  back,  the  lower  border  of  the  spleen  was  found  to  reach 
to  the  left  crest  of  the  ilium,  and  the  inner  margin  passed  obliquely  down- 
wards from  beneath  the  ribs  to  within  two  fingers'-breadth  of  the  right 
anterior  superior  spine  of  the  ilium.  The  notch  was  felt  just  above  the 
umbilicus.  The  organ  was  freely  movable,  descending  appreciably  in  in- 
spiration, and  it  could  be  pushed  upAvards  until  its  lower  border  Avas  on  a 
level  Avith  the  navel.  Its  substance  was  firm  and  hard,  and  its  surface 
smooth.  The  upper  border,  estimated  by  percussion,  rose  to  within  two 
fingers'-breadth  of  the  inferior  angle  of  the  left  scapula.  The  edge  of 
the  liver  Avas  one  inch  below  the  costal  margin.  A  small  nodule  could  be 
felt  on  each  side  behind  the  ramus  of  the  lower  jaw  ;  otherwise  there  was 
no  enlargement  of  the  lymphatic  glands.  A  little  blue  mark,  like  a  bruise, 
was  noticed  on  the  forehead,  and  there  was  another  on  the  back,  but  there 
were  no  petechise  present  on  the  skin.  There  was  no  oedema  of  the  legs. 
The  child's  appetite  was  good,  and  he  was  not  suffering  from  digestive  dis- 
turbance. An  examination  of  the  blood  showed  no  excess  of  white  cor- 
puscles. 

Children  in  whom  great  enlargement  of  the  spleen  exists  are  very  sub- 
ject to  gastro-intestinal  troubles,  and  in  consequence  of  their  weakness  are 
frequent  sufferers  from  every  form  of  catarrhal  derangement.  In  fact, 
they  usually  die  from  a  severe  diarrhoea  or  an  attack  of  bronchitis  or  ca- 
tarrhal pneumonia.  If  they  escape  these  accidents  recovery  is  not  impossi- 
ble. We  sometimes  find  the  spleen  gradually  diminish  in  size  and  eventu- 
ally return  to  its  normal  dimensions. 

A  little  boy,  aged  twelve  months,  Avith  no  teeth,  was  brought  to  me,  as 
he  was  said  to  be  weakly.  The  child  had  been  reared  by  hand,  and  was 
subject  to  attacks  of  sickness.  A  short  time  previously,  during  a  Adsit  to 
the  seaside,  he  had  been  jaundiced.  There  Avas  some  slight  enlargement 
of  the  ends  of  the  bones  and  his  fontanelle  Avas  large.  The  child  could 
not  stand,  but  liked  to  be  danced  about  and  played  with.  His  complexion 
was  excessively  pale,  Avith  a  faint  olive  cast.  The  abdomen  was  full,  and 
the  spleen,  which  was  large  and  hard,  reached  to  the  level  of  the  navel. 
The  child  was  put  upon  a  nutritious  diet,  and  Avas  ordered  cod-liver  oil 


240  DISEASE   IIN"    CIIILDEElSr. 

and  plenty  of  fresh  air.  In  five  montlis'  time  he  had  cut  ten  teeth,  and 
although  still  pale,  had  a  better  complexion.  Seven  months  afterwards 
(twelve  from  his  first  visit)  he  had  sixteen  teeth  and  could  run  about  well. 
His  spleen  was  now  greatly  reduced  in  size,  being  just  perceptible  below 
the  ribs.     His  complexion  was  good  and  he  seemed  perfectly  well. 

In  this  case  no  special  medication  was  attempted  with  the  object  of 
reducing  the  size  of  the  spleen.  The  general  weakly  state  was  improved 
by  fresh  air  and  a  suitable  dietary,  and  cod-liver  oil  was  given  on  accoimt 
of  the  signs  of  incipient  rickets.  Moreover,  further  intestinal  catarrhs 
were  prevented  by  a  carefuUy  applied  abdominal  bandage.  The  hope  that 
under  these  altered  conditions  the  size  of  the  spleen  would  diminish  as  the 
general  health  improved  was  perfectly  justified  by  the  event. 

Diagnoi^is. — There  is  little  difficulty  about  the  diagnosis  of  these  cases. 
The  complexion  of  the  child  is  very  characteristic.  Indeed,  in  a  young 
child  extreme  aneemia  should  always  direct  attention  to  the  spleen.  When 
a  hard  lump  is  discovered  in  the  left  side  of  the  abdomen,  it  is  easy 
to  ascertain  if  the  swelling  is  due  to  splenic  enlargement.  The  superficial 
position  of  the  tumour ;  its  passing  upwards  beneath  the  ribs  ;  its  less 
rounded  inner  edge,  with  a  perceptible  notch  ;  the  free  mobility  of  the 
mass,  which  can  be  pressed  upwards  by  the  fingers,  and  may  be  seen  to 
move  in  correspondence  with  respiration,  descending  when  a  deep  breath 
is  drawn,  and  rising  again  Avith  the  diaphragm  as  the  lungs  contract — all 
these  signs  leave  little  doubt  of  the  nature  of  the  enlargement.  That  the 
tumefaction  is  a  simj)le  hypertrophy,  and  is  not  due  to  lymphadenoma  or 
leucocythemia,  is  inferred  from  the  absence  of  lymphatic  enlargements  in 
the  former  case,  and  in  the  latter  from  the  small  increase  in  number  of  the 
white  corjDuscles  of  the  blood. 

Prognosis. — The  prospects  of  the  child  in  simple  hyperplasia  of  the 
spleen  depend  in  a  great  measure  upon  the  care  bestowed  upon  him,  and 
the  watchfulness  with  which  he  is  guarded  from  intercurrent  ailments. 
The  prognosis  is. therefore  much  more  favourable  in  the  case  of  children  of 
well-to-do  parents  than  in  those  belonging  to  the  class  by  which  our  hos- 
pitals are  supplied.  If  the  patient  show  marked  signs  of  rickets  or  syphi- 
lis, a  cure  can  hardly  be  anticipated  ;  but  if  the  signs  of  rickets  are  only 
moderately  developed,  or  the  syphilitic  origin  of  the  enlargement  is  merely 
a  matter  of  suspicion,  the  child,  under  favourable  conditions,  has  a  fair 
chance  of  recovery.  Any  considerable  excess  of  white  corpuscles  in  the 
blood  must  greatly  diminish  our  hopes  of  a  successful  termination  to  the 
case. 

Treatment. — In  the  treatment  of  cases  of  simple  hypertrophy  of  the 
spleen  we  must  not  allow  our  attention  to  be  directed  too  exclusively  to 
the  swollen  organ,  to  the  neglect  of  the  general  health.  Much  injury  is 
often  done  in  these  cases  by  long  courses  of  mercury  or  iodide  of  potas- 
sium, and  the  energetic  application  of  mercurial  ointments  to  the  left 
hypochondrium. 

Our  first  care  should  be  to  attend  to  any  gastro-intestinal  derangement 
which  may  be  interfering  with  the  patient's  nutrition.  Vomiting  must  be 
stojDped,  looseness  of  the  bowels  must  be  arrested,  and  the  diet  must  be 
arranged  so  as  to  supply  the  most  ample  nourishment  with  the  least  tax 
upon  the  digestive  powers.  Most  of  the  patients  are  weakly  cliildren 
under  two  years  of  age.  They  must  therefore  be  dieted  upon  the  prin- 
ciples recommended  in  the  chapter  on  Infantile  Atrophy.  Milk,  yolk  of 
egg,  MeUin's  food,  Chapman's  baked  flour,  broths,  thin  bread  and  butter, 
and,  if  the  child  is  eighteen  months  old,  raw  or  underdone  mutton,  pounded 


ENLARGEMENT  OF  THE  SPLEEN" — DIAGNOSIS — TREATMENT.     241 

in  a  mortar  and  strained  through  a  fine  sieve,  should  be  given.  Watch- 
fulness must  be  exercised  that  the  size  and  frequency  of  the  meals  are 
duly  proportioned  to  the  digestive  capabilities  of  the  patient ;  and  in  the 
case  of  milk,  in  particular,  it  is  important,  by  careful  inspection  of  the 
stools,  to  satisfy  ourselves  that  curd  is  not  passing  away  in  large  quantities 
by  the  bowels.  If  this  be  the  case,  milk  should  not  be  given  pure  as  a 
drink,  but  be  always  mixed  with  barley-water  or  other  thickening  material, 
so  as  to  aid  its  digestion  by  insuring  a  fine  division  of  the  curd.  Three 
or  four  grains  of  pepsine,  given  just  before  the  three  principal  meals,  will 
be  of  great  assistance  in  these  cases. 

Having  attended  to  the  diet,  attention  should  next  be  directed  to  the 
clothing  of  the  child.  These  patients,  especially  if  they  show  any  signs  of 
rickets,  are  very  sensitive  to  changes  of  temperature,  and  it  is  of  extreme 
importance  that  they  should  be  thoroughly  protected  from  chills.  The 
belly  should  be  covered  with  a  broad  flannel  belt.  This  must  be  applied 
carefully,  so  as  to  cover  the  whole  of  the  abdomen,  from  the  hips  to  the 
waist,  and  should  fit  closely  to  the  skin.  In  cold  or  changeable  weather 
the  child's  legs  and  thighs  should  be  protected  by  long  woollen  stockings, 
and  all  his  underclothing  should  be  of  flannel  or  wool.  So  protected,  the 
patient  must  be  taken  out  of  doors  as  much  as  possible,  and  in  suitable 
weather  should  pass  the  greater  part  of  the  day  out  of  the  house.  Before 
he  leaves  home,  his  feet  should  be  examined  to  see  that  they  are  perfectly 
warm  ;  and  in  cold  weather  it  is  best  to  pack  the  child  in  a  perambulator, 
so  that  his  back  and  sides  may  be  properly  supported.  His  feet  can  then 
rest  upon  a  hot- water  bottle.  If  the  patient  be  sent  to  a  good  seaside  air, 
the  effect  of  these  measures  is  often  very  marked. 

For  medicine,  unless  there  are  positive  signs  of  syphilis,  mercurials 
and  other  lowering  drugs  should  not  be  employed.  The  best  treatment 
consists  in  the  use  of  iron  in  full  doses  and  cod-liver  oil ;  but  this  treat- 
ment must  not  be  begun  until  the  bowels  have  been  put  into  a  healthy 
state  by  appropriate  remedies.  For  a  child  of  eighteen  months  of  age 
two  or  three  grains  of  the  exsiccated  sulphate  of  iron  may  be  given  in  gly- 
cerine ;  or  ten  drops  of  the  tincture  of  perchloride  of  iron  may  be  adminis- 
tered, freely  diluted  with  water  and  sweetened  with  glycerine,  three  times 
a  day  after  meals.  Quinine  is  also  of  service,  and  may  be  given  in  con- 
junction with  the  iron.  The  value  of  alcohol  must  not  be  forgotten.  A 
teaspoonful  of  the  St.  Raphael  tannin  wine,  given  two  or  three  times  a 
day,  diluted  with  an  equal  quantity  of  water,  is  an  important  addition  to 
the  treatment. 

I  have  employed  frictions  with  mercurial  salves  to  the  splenic  region, 
and  seen  them  used  by  others,  but  have  never  noticed  any  special  benefit 
from  this  proceeding.  As  a  rule,  it  has  seemed  to  me  that  the  ansemia 
has  been  intensified  by  this  means,  and  that  the  size  of  the  spleen  has  in- 
creased rather  than  diminished  under  the  use  of  the  drug.  Unless  the 
employment  of  the  remedy  is  distinctly  indicated  by  clear  evidence  of  the 
presence  of  syphilis  in  the  child,  this  method  of  treatment  seems  likely  to 
be  attended  with  a  bad  rather  than  a  good  result. 
16 


CHAPTEE    V. 

HEMOPHILIA. 

HEMOPHILIA  is  a  congenital  tendency  to  bleeding  whicli  manifests  itself 
shortly  after  birth  and  lasts  the  life  of  the  patient.  The  haemorrhage  oc- 
curs either  spontaneously  or  upon  slight  provocation,  and  can  only  be 
arrested  with  great  difficulty.  The  subjects  of  the  disease  also  exhibit  a 
curious  tendency  to  obstinate  swellings  of  the  joints,  which  are  often 
siDoken  of  as  "  rheumatism."  A  temporary  disposition  to  haemorrhages, 
such  as  is  sometimes  left  after  certain  diseases,  does  not  constitute  hsemo- 
philia.  The  true  disease  dates  from  birth,  or  appears  shortly  after  it ;  is 
always  seen  in  childhood,  and  persists,  as  a  rule,  to  the  very  end  of  life. 

Causation. — Haemophilia,  if  not  invariably  hereditary,  shows  a  singular 
tendency  to  hereditary  transmission.  The  proclivity  manifests  itself  more 
frequently  in  the  male  than  in  the  female  offspring  ;  but  the  females,  if 
themselves  exempt  from  this  peculiarity,  are  still  capable  of  transmitting 
the  disease  to  their  children.  It  is,  indeed,  a  curious  fact  that  the  trans- 
mission of  the  tendency  to  the  child  is  seen  more  commonly  in  cases  where 
the  patient,  whether  male  or  female,  although  sprung  from  a  family  of 
bleeders,  is  individually  free  from  the  hsemorrhagic  disposition.  It  is  rare 
to  find  a  father  transmit  the  disease  to  his  child  if  he  is  himself  a  sufferer. 
In  the  majority  of  cases  the  unfortunate  mheritance  is  derived  from  the 
mother,  who  has  probably  escaped. 

In  a  family  subject  to  this  tendency  all  the  male  children  may  prove 
bleeders.  Sometimes,  however,  one  or  more  escape.  Dr.  Wickham  Legg 
is  of  opinion  that  when  transmission  is  only  partial  the  first-born  are  more 
exempt  than  the  others.  The  disease  is  found  in  all  countries  and  all  con- 
ditions of  life.     The  Hebrew  race  is  said  to  be  pecuharly  liable  to  it. 

Morbid  Anatomy. — In  cases  of  death  from  hasmophiha  Httle  is  found  to 
explain  the  nature  of  the  disease.  The  body  is  usually  blanched  from  loss 
of  blood,  but  the  organs,  especially  the  heart  and  large  vessels,  present  no 
appearance  of  disease.  No  change  is  discovered  in  the  blood,  and  the 
vessels  seldom  present  any  alterations  recognisable  by  the  microscope'  In 
some  cases,  indeed,  a  partial  fatty  degeneration  of  the  lining  membrane  of 
the  arteries  has  been  observed ;  but  this  is  probably  the  consequence  of 
the  ansemia.  Petechise  in  the  skin,  and  bruise-hke  patches  from  subcuta- 
neous extravasation,  may  be  found  ;  and  sometimes  large  collections  of 
blood  have  been  met  with.  Sir-  "W.  Jenner  has  reported  the  case  of  a  boy, 
aged  thirteen  years,  in  whom  an  enormous  extravasation  of  blood  was  dis- 
covered beneath  the  fascia  of  the  right  thigh.  The  swelling  of  the  joints 
appears. to  be  due  to  extravasation  of  blood  into  the  articulations.  In  a 
case  reported  by  M.  Poncet,  on  opening  the  knee-joint,  which  had  been 
obstinately  swollen  and  painful  during  life,  all  the  tissues  of  the  articula- 
V  tion  were  found  to  be  stained  with  blood.  At  the  circumference  the  tis- 
sues were  chocolate-coloured  ;  the  articular  surfaces  were  red  and  impreg- 


HJj:MOPHILIA — morbid   AjSTATOMY — SYMPTOMS.  243 

nated  with  blood  ;  and  tlie  cartilages  were  the  seat  of  advanced  lesions 
such  as  have  been  described  by  Charcot  as  characteristic  of  chronic  rheu- 
matism. Microscopic  examination  revealed  in  the  substance  of  the  tissues 
yellow  granules,  irregular  or  rounded,  and  of  variable  size,  pigment  gran- 
ules, and  fat  granules.  Other  joints  in  the  same  subject  showed  similar 
lesions. 

Symptoms. — There  is  nothing  in  the  look  of  the  child  at  birth  to  indi- 
cate any  peculiarity  of  constitution.  Nor  in  after  years,  unless  the  indi- 
vidual be  actually  suffering  from  loss  of  blood  or  disease  of  the  joints,  is 
there  anything  in  his  appearance  to  distinguish  him  from  another  without 
the  same  tendency  to  bleed.  The  child  may  be  fair  or  dark,  tall  or  short, 
of  robust  frame  or  of  slender  build.  As  a  rule,  he  looks  healthy,  and  his 
intellectual  capacity  is  above  the  average. 

It  is  rarely  before  the  end  of  the  first  twelve  months  of  life  that  any 
sign  is  noticed  of  the  hsemorrhagic  disposition.  Bleeding  seldom  occurs  at 
the  time  of  separation  of  the  umbilical  cord,  or  during  the  operation  of 
vaccination  ;  and  it  is  not  until  the  infant  is  able  to  crawl  or  walk,  and 
thus  becomes  exposed  to  injuries  from  faUs  or  other  violence,  that  his  con- 
stitutional peculiarity  can  be  recognised.  Sometimes,  however,  evidence 
of  the  disease  is  postponed  until  later.  Bleeding  may  not  be  noticed  until 
the  second  crop  of  teeth  begins  to  make  its  appearance  at  about  the  sixth 
year.  It  has  even  been  known  to  come  on  for  the  first  time  at  a  later 
period  ;  but  is  rarely  delayed  till  after  puberty. 

The  propensity  to  bleed  varies  greatly  in  its  intensity  in  different  sub- 
jects. In  the  lowest  degree  it  may  show  itself  merely  in  the  shape  of 
ecchymoses  in  the  skin.  In  a  higher  grade  the  patient  may  complain  of 
spontaneous  haemorrhage  from  the  mucous  membranes.  In  its  most  pro- 
nounced form  a  tendency  to  every  kind  of  bleeding  is  observed.  The 
mucous  membranes  may  pour  out  blood  without  obvious  cause  ;  slight  in- 
juries may  give  rise  to  copious  extravasation  into  the  tissues  ;  petechia 
may  appear  in  the  skin  ;  and  obstinate  and  painful  swellings  may  attack 
the  joints. 

The  hgemorrhage  usually  occurs  at  a  time  when  the  patient  appears  to 
be  in  unusually  good  health,  for  it  is  at  these  times  that  there  is  a  plethora 
of  the  smaller  vessels.  The  bleeding  may  be  preceded  by  signs  of  excite- 
ment or  irritability  of  temper,  and  it  is  said  that  there  is  sharpening  of 
the  senses  of  hearing  and  of  sight.  Ej)ileptiform  convulsions  have  been 
noticed  in  one  case  by  Boier. 

If  the  bleeding  be  spontaneous,  it  occurs  in  the  child  usually  from  the 
nose  ;  but  may  be  also  noticed  from  the  inside  of  the  cheeks  and  lips,  and 
from  the  gums,  especially  during  dentition.  In  less  common  cases  blood 
is  also  poured  out  from  the  mucous  membrane  of  the  stomach  and  bowels, 
and  may  be  vomited  up  or  discharged  by  stool.  As  a  rule,  the  younger 
the  child  the  more  likely  is  the  haemorrhage  to  come  from  the  nose  or 
mouth.  It  is  only  towards  puberty  that  haematemesis  or  melaena  becomes 
common.  Renal  haemorrhage  is  rare.  Once  started,  the  loss  of  blood  may  be 
continuous  and  copious,  so  as  to  be  arrested  with  the  greatest  difficulty  ;  or 
may  cease  for  a  time  and  then  return.  Sometimes  haemorrhage  from  one 
source  is  quickly  followed  by  a  similar  effusion  from  another,  until  the  pa- 
tient dies  worn  out  by  the  constant  discharge.  When  bleeding  from  one 
source  alone  ends  in  death,  the  haemorrhage  occurs  usually  from  the  nose. 

In  addition  to  the  spontaneous  haemorrhages,  slight  wounds  or  blows 
may  produce  a  copious  effusion.  Little  cuts  or  scratches  bleed  obstinately  ; 
shght  blows  upon  the  body  may  be  a  cause  of  serious  extravasation  ;  and 


244  DISEASE   IN   CHILDEEX. 

in  certain  subjects  even  tlie  rising  of  a  blister  may  fill  the  bleb  mtb  blood, 
instead  of  serum.  In  such  patients  the  extraction  of  a  tooth,  the  apj)hca- 
tion  of  a  leech,  or  the  prick  of  a  pin  may  induce  bleeding  Tvhich  for  a  long 
time  resists  the  most  powerful  styptics,  and  may  even  destroy  the  hfe  of 
the  patient  in  spite  of  the  most  energetic  measui'es  for  its  suppression. 

The  tendency  to  bleed,  even  in  the  case  of  the  same  child,  is  subject  to 
curious  variatiou.  A  slight  injiuy  which  at  one  time  gives  rise  to  exces- 
sive haemorrhage,  at  another  is  followed  by  no  iO.  consequences  ;  and  a 
child  in  whom  repeated  haemorrhages  from  the  nose  or  mouth  are  a  source 
of  anxiety  may  bear  the  removal  of  a  tooth  without  imusual  bleeding  fol- 
lowing the  operation.  Thus  Dr.  Wickham  Legg  has  reported  the  case  of 
a  boy,  aged  eight  years,  who  was  subject  to  fi'equent  haemorrhages  from 
the  nose  and  gums.  This  child  could  bear  the  extraction  of  a  tooth  or  a 
cut  on  the  finger  without  much  loss  of  blood. 

In  all  cases  the  source  of  the  bleeding  is  capillary.  The  hfemorrhage- 
occurs  as  a  constant  oozing,  which  may  last  for  hours,  days,  or  weeks  ;  and 
it  is  astonishing  to  note  the  enormous  quantity  of  blood  which  may  be 
thus  poured  out  by  the  most  trifling  wound.  In  the  case  of  traumatic 
bleeding  the  heemorrhage  usually  begins  some  houi's  after  the  infliction  of" 
the  injruy.  It  often  does  not  cease  rmtil  the  patient  becomes  faint,  and 
even  then  is  liable  to  renewal  when  consciousness  retru-ns.  By  this  means 
the  child  may  be  reduced  to  a  state  of  profound  ansemia,  and  only  slowly 
regains  his  coloui*  and  strength. 

The  petechia?  and  subcutaneous  ha?moiThages  which  occur  in  hamo- 
phiHa  are  very  similar  to  those  noticed  in  cases  of  piu-pui-a.  They  are  com- 
mon on  the  buttocks  and  limbs  of  infant  bleeders,  but  the  face  usually  es- 
capes. Trifling  blows  may  produce  coj)ious  effusions.  In  some  cases  the 
blood  infiltrates  extensively  through  the  areolar  tissue  of  a  limb,  and  deatk 
may  even  ensue  from  this  inward  bleeding.  In  other  cases  cii'cumscribed 
collections  of  blood  may  be  noticed,  forming  tumours  of  various  sizes. 

One  of  the  most  curious  featui-es  of  the  disease  in  its  higher  grade  is 
the  joint  affection  to  which  these  patients  are  so  subject.  The  articula- 
tions attacked  are  usually  the  larger  ones,  and  in  the  majority  of  cases  it 
is  the  knee  which  suffers  ;  but  the  ankles  and  hips,  the  shoulders  and  el- 
bows are  liable  to  be  affected.  The  joint  becomes  swollen  and  tender,  and 
the  swelling  usually  increases  until  the  ends  of  the  bones  can  no  longer  be- 
felt.  It  is  accompanied  by  pain  which  is  increased  by  movement,  and 
there  is  a  rise  of  temperature.  Sometimes  fluctuation  may  be  detected. 
The  swelling  is  said  to  be  due,  in  some  cases,  to  a  simple  effusion  into  the- 
joint ;  but  it  is  more  commonly  the  consequence  of  articular  haemorrhage. 
It  may  occur  either  spontaneously  or  as  the  result  of  a  trifling  injiuy.  The 
symptom  persists  for  a  variable  time,  and  it  may  be  months  before  the- 
joint  returns  to  its  ordinary  dimensions.  Several  joints  may  be  attacked  in 
succession,  or  the  joint  affection  may  alternate  with  some  form  of  visible 
haemorrhage.  Blood  tumours  sometimes  rise  on  the  sides  of  a  diseased 
joint.  Thus  M.  Poncet  has  recorded  the  case  of  a  boy,  aged  sixteen,  whose 
right  knee  had  been  painful,  stiff,  and  swollen  for  two  years.  Some  time 
jDreviously  a  smaU.  swelhng  had  formed  on  the  inner  side  of  the  knee. 
This  had  turned  black,  and  then  had  bui'st,  giving  rise  to  obstinate  haemor- 
rhage. The  boy  was  very  subject  to  profuse  bleedings  from  the  nose, 
and  eventually  died  in  consequence  of  repeated  haemorrhage  from  woTinds 
made  by  the  application  of  the  actual  cautery  to  the  diseased  joint. 

In  addition  to  the  articular  affection,  pains  may  be  complained  of  in 
the  limbs  about  the  joints,  although  unaccompanied  by  swelling.     These 


HEMOPHILIA — SYMPTOMS — DIAGIN'OSIS.  245 

may  be  so  severe  as  to  interfere  with  exercise.  The  subjects  of  hsemo- 
l^hilia  also  suffer  much  from  cold,  and  the  haemorrhage  may  be  determined 
by  exposure  to  weather. 

It  might,  perhaps,  be  expected  that  the  existence  of  the  constitutional 
tendency  would  influence  xmfavourably  the  course  of  the  exanthemata  and 
other  intercuiTent  diseases  to  which  childhood  is  liable  ;  but  this  does  not 
appear  to  be  the  case.  Measles,  scarlet  fever,  and  whooping-cough  are 
said  to  run  their  normal  course  in  such  subjects  without  manifesting  ex- 
ceptionally unfavourable  symptoms  ;  and  although  the  patients  are  prone 
to  chest  affections,  such  as  pleurisy  and  pneumonia,  these  diseases  are  not 
attended  with  special  dangers.  There  is  no  peculiar  liability  to  phthisis  ; 
but  sloughing  and  gangrene  are  said  to  be  not  uncommon  accidents  in  the 
course  of  wounds  and  traumatic  injuries  generally. 

Diagnosis. — In  pronounced  cases  the  detection  of  the  hsemorrhagie 
tendency  is  a  matter  of  little  difficulty.  The  histoiy  of  repeated  bleedings, 
the  habitual  appearance  of  bruises  upon  slight  injury,  and  the  affection  of 
the  joints,  furnish  sufficient  evidence  of  the  existence  of  this  constitutional 
pecuUarity.  In  cases  where  the  tendency  is  present  in  a  less  degree  the 
diagnosis  is  not  so  easy.  Repeated  epistaxis  is  often  seen  in  childi-en 
whose  health  in  other  resjpects  is  perfectly  satisfactory  ;  and  the  occurrence 
of  spontaneous  haemorrhage  from  this  source  is  therefore  of  no  value  in 
establishing  the  existence  of  ha^moj^hiiia.  Again,  profuse  and  even  fatal 
bleeding  from  the  stomach  and  bowels  may  be  met  with  in  new-born  in- 
fants. The  cause  of  hsemorrhage  in  the  newly-born  is  often  obscure  ;  and 
in  the  absence  of  any  evident  reason  for  its  occurrence  some  observers 
have  attributed  it  to  a  special  htemorrhagic  tendency  existing  in  the  in- 
fant. This  may  be  so  ;  but  the  cases  differ  from  hsemophiha  in  the  fact 
that  where  hfe  is  preserved  no  special  proneness  to  bleeding  is  manifested 
in  after  years  (see  page  655).  So,  also,  in  hremorrhagic  purpura  profuse 
bleeding  may  occur  from  all  the  mucous  surfaces  and  into  the  tissues  ;  but 
the  disposition  to  bleed  is  here,  also,  a  temporary  infii'mity  which  passes 
off  and  is  completely  recovered  from. 

In  all  cases  of  true  hfemophiha  careful  inquiry  will  discover  the  exis- 
tence of  a  hereditary  tendency,  especiaUy  on  the  side  of  the  mother,  and 
also  in  most  cases  a  disposition  on  the  part  of  the  child  liimself  to  bleed 
profusely  upon  slight  provocation. 

The  nature  of  the  joint  affection  can  only  be  discovered  by  establishing 
the  existence  of  the  hfemorrhagic  tendency  ;  for  there  is  nothing  in  the 
character  of  the  joint  symptoms  to  distinguish  the  swelling  from  that  pro- 
duced by  other  causes. 

Prognosis. — Haemophilia  is  a  disease  which  is  accompanied  by  serious 
danger  to  life.  The  exhaustion  j)roduced  by  repeated  hiemorrhages  is  so 
gi'eat  that  comparatively  few  of  the  patients  reach  adult  years.  Out  of  one 
hundred  and  fifty-two  boys,  the  subjects  of  the  haemorrhagic  disposition, 
Grandidier  found  that  only  nineteen  attained  the  age  of  twenty-one,  and 
that  more  than  half  of  the  number  died  before  completing  theu*  seventh 
year.  Death  usually  occui-s  from  hsemorrhage,  but  some  kinds  of  bleeding 
appear  to  be  more  unfavourable  than  others.  Thus  haemoiThage  after  ex- 
traction of  a  tooth  is  found  to  be  especially  dangerous  ;  obstinate  ej)is- 
taxis  is  also  to  be  viewed  with  gi-ave  apprehension  ;  indeed,  to  these  two 
varieties  of  bleeding  a  large  proportion  of  the  deaths  may  be  attributed. 

Children  are  said  rarely  to  die  from  a  first  bleeding,  and  one  profuse 
gush  which  causes  fainting  is  thought  to  be  more  favoiu'able  than  a  slower 
and  persistent  oozing.     Still,  in  any  case  we  should  speak  very  cautiously 


246  DISEASE  IN   CHILDEEN. 

of  the  future,  wlietlier  immediate  or  remote  ;  for  if  the  tendency  be  pro- 
nounced, the  boy's  chances  of  growing  into  manhood  are  not  promising. 

Treatment.— In  cases  of  haemophilia  great  care  shoiild  be  taken  to  pro- 
tect the  child  from  all  forms  of  injur}^  Vaccination  has  been  seldom  fol- 
lowed by  dangerous  bleeding  ;  but  the  operation  should  be  performed,  as 
Dr.  Wickham  Legg  suggests,  rather  by  scarification  than  by  punctui-e. 
Surgical  operations,  even  of  the  simplest  kind,  should  be  undertaken  only 
as  a  last  resource,  and  the  extraction  of  a  tooth  should  be  expressly  for- 
bidden. 

Constipation  is  Hkely  to  be  particularly  injurious  to  the  subjects  of 
hgemophiha.  Therefore  it  is  very  important  to  see  that  the  bowels  are 
properly  reheved.  The  child  should  take  a  dose  of  gray  powder  with  jala- 
pine  every  tw-o  or  three  weeks,  followed  by  a  saline  ;  and  the  latter,  in  the 
shape  of  Dinneford's  magnesia  or  the  granular  citrate  of  magnesia,  may  be 
o-iven  regularly  every  week.  The  dietary  should  include  a  good  proportion 
of  vegetables  ;  and  the  white  meats  and  fish  are  preferable  to  too  much 
beef  and  mutton.  In  case  any  of  the  premonitory  symptoms  of  haemor- 
rhage are  observed,  all  meats  should  be  at  once  forbidden,  and  a  mercnrial 
purge  be  administered,  followed  by  a  sahne.  Regular  exercise  should  be 
enforced  ;  but  boisterous  games,  such  as  cricket,  foot-ball,  etc.,  can  only 
be  indulged  in  at  a  great  risk. 

When  bleeding  occurs,  the  treatment  will  depend  upon  the  source  of 
the  hsemorrhage.  If  this  be  at  the  surface,  so  that  pressure  can  be  brought 
to  bear  upon  the  part,  as  in  the  case  of  a  cut  or  other  injury,  the  apphca- 
tion  of  a  graduated  compress,  after  careful  cleaning  of  the  wound,  should 
be  had  recourse  to.  The  local  use  of  perchloride  of  iron,  nitrate  of  silver, 
and  other  styptics,  and  of  ice,  is  also  recommended.  In  cases  of  sponta- 
neous haemorrhage  astringents  apphed  locaUy  are  our  chief  resource.  In 
epistaxis  the  nasal  passages  must  be  first  cleared  out  by  injections  of  ice- 
cold  water.  Afterwards  the  solution  of  perchloride  of  iron  (of  the  strength 
of  one  drachm  of  the  strong  solution  to  an  ounce  of  water)  should  be  in- 
jected or  sprayed  into  the  nostrils.  If  this  method  fail,  the  anterior  and 
posterior  nares  must  be  plugged.  If  the  hsemorrhag-e  occur  from  the 
socket  of  a  tooth,  crystals  of  the  perchloride  of  hon  apphed  locaUy  will 
sometimes  arrest  it ;  or  the  alveolus  may  be  packed  with  a  graduated  com- 
press soaked  in  the  iron  solution.  Bleeding  from  the  bowels  usually  comes 
from  the  lower  part  of  the  rectum,  and  can  often  be  staunched  by  injec- 
tions of  the  iron  solution  (one  or  two  drachms  to  the  ounce).  Bleeding 
from  the  gums  is  usually  stopped  by  washes  of  tannin,  alum,  or  rhatany  ; 
and  the  child  should  be""  prevented  if  possible  from  encoui-aging  the  bleed- 
ing by  sucking  his  gums.  Iron  and  other  styptics  given  internally  seem 
to  be  of  small  value  ;  but  ergot  is  stated  to  have  proved  of  service. 

The  subjects  of  this  tendency  should  be  warmly  dressed  and  carefully 
protected  from  the  cold.  If  possible  their  residence  should  be  elsewhere 
than  in  cold,  damp  situations.  The  joint  affection  must  be  treated  by  per- 
fect rest,  and  cold  or  warm  applications  as  are  most  agreeable  to  the  patient. 
At  a  late  stage  bhsters  to  the  joint  are  said  to  be  useful,  but  counter-irri- 
tation with  the  actual  cautery  is  to  be  avoided. 


CHAPTER  YI. 

PURPURA. 

PuRPTTEA  is  a  diseased  condition  in  which  extravasations  of  blood  take  place 
into  the  skin  and  the  substance  of  the  viscera,  and  blood  may  be  poured 
out  from  many  mucous  surfaces  and  into  the  serous  cavities.  "When  the 
extravasation  takes  place  into  the  skin  it  is  called  puiyura  simplex  ;  when 
the  haemorrhage  is  more  general  the  disease  goes  by  the  name  of  purpura 
hcemorrhagica.  Many  acute  forms  of  illness,  febrile  and  other,  are  accom- 
panied by  the  ready  escape  of  blood  from  the  vessels.  In  the  malignant 
forms  of  scarlatina,  measles,  small-pox,  typhus  fever,  and  diphtheria  purpuric 
spots  and  haemorrhages  are  seldom  absent ;  and  the  same  symptom  is 
found  in  scurvy,  and  is  occasionally  met  with  in  cases  of  Bright's  disease, 
cirrhosis  of  the  liver,  leucocythemia,  and  valvular  lesions  of  the  heart. 
Strictly  speaking,  however,  the  term  purpura  is  applied  to  a  temporary 
haemorrhagic  tendency  unconnected  with  any  of  the  acute  specific  diseases, 
and  in  which  no  morbid  condition  of  organs,  other  than  that  due  to  the 
extravasation  and  its  consequences,  can  be  discovered. 

Cg,usation. — Purpura  is  common  in  children,  and  appears  in  many  cases 
to  be  a  consequence  of  insanitary  conditions  and  insufficient  food.  Still, 
that  the  disease  may  arise  from  other  causes  is  shown  by  the  well-nour- 
ished state  and  robust  appearance  of  many  of  the  subjects  of  this  disorder. 
The  haemorrhagic  tendency  is  sometimes  seen  to  come  on  quite  suddenly 
without  apparent  cause  in  one  member  of  a  healthy  family,  the  others 
who  appear  to  be  Hving  in  precisely  the  same  conditions  escaping  alto- 
gether. Thus,  a  robust  little  boy,  aged  six  years,  one  of  eight  healthy 
children  and  born  of  healthy  parents  without  any  history  of  haemorrhagic 
tendency,  had  himself  been  strong  and  well  all  his  life  with  the  exception 
of  attacks  of  measles  and  whooping-cough  during  his  second  year.  The 
boy  suddenly  began  to  bleed  from  the  eyes,  the  nose,  and  the  mouth,  and 
soon  developed  all  the  symptoms  of  severe  haemorrhagic  purpura.  In 
cases  such  as  this  the  occurrence  of  the  disease  can  never  be  traced  to 
error  in  diet  or  insufficiency  of  vegetable  food  or  milk.  Sometimes  pur- 
pura may  come  on  as  a  sequel  of  an  exhausting  disease,  such  as  scarlatina 
and  typhoid  fever,  and  I  have  known  it  to  occur  after  a  severe  attack  of 
croupous  pneumonia.  It  is  said,  too,  to  be  occasionally  induced  by  the 
administration  of  iodide  of  potassium  in  weakly  subjects,  especially  in 
those  labouring  under  valvular  disease  of  the  heart.  In  many  cases,  how- 
ever, no  antecedent  condition  of  any  kind  can  be  discovered  capable  of 
explaining  the  sudden  proj)ensity  to  bleed. 

Morbid  Anatomy. — In  the  skin  the  haemorrhage  occurs  in  the  rete  mu- 
cosum  and  the  papillary  layer  of  the  cutis,  and  also  into  the  subcutaneous 
tissue.  The  submucous  tissue  is  also  often  the  seat  of  extravasation,  and 
sometimes  much  blood  is  poured  oiit  from  the  surface  of  the  mucous 
membrane.     In  this  way,  after  death  purple  spots  and  extravasations  of 


248  DISEASE  IIN"   CHILDREN". 

■various  sizes  may  be  discovered  beneath  the  mvicoiis  membrane  of  the 
moiith,  gullet,  stomach,  and  intestine  both  small  and  large.  So  also 
the  serous  surfaces  and  subserous  tissues  may  suffer  in  the  same  way, 
and  more  or  less  copious  extravasation  may  be  found  in  the  serous 
cavities — the  j)leura,  the  peritoneum,  and  the  pericardium.  The  substance 
of  organs  is  not  unfi-equently  the  seat  of  haemorrhage,  and  clots  may  form 
in  the  lungs,  the  heart,  the  kidneys,  etc.  Fatal  apoplexy  may  also  result 
from  this  cause. 

Pure  pui-pura  does  not  lead  to  disease  of  internal  organs.  If  the 
anaemia  be  extreme,  fatty  degeneration  of  the  muscular  fibres  of  the  heart 
and  a  similar  condition  of  other  viscera  may  be  found  ;  but  this  is  a  conse- 
quence of  the  impoverished  state  of  the  blood  induced  by  repeated  hsemor- 
rhages,  and  is  only  a  secondary  consequence  of  the  ha3morrhagic  tendency. 
Amyloid  and  other  degenerations  foimd  in  the  hver  and  elsewhere  must 
be  looked  upon  as  a  result  with  the  purpura  of  a  common  cause.  When 
bleeding  is  profuse  and  repeated  the  blood  undergoes  the  changes  inci- 
dent to  an  advanced  stage  of  anaemia,  the  amount  of  haemoglobin  is  less- 
ened, and  the  red  coi-puscles  are  diminished  in  number  as  well  as  reduced 
in  size.  Unless  the  blood  be  impoverished  by  haemorrhages,  no  morbid 
change  in  the  fluid  can  be  detected. 

"With  regard  to  the  pathology  of  the  disease,  the  fault  has  been  sup- 
posed to  lie  in  some  alteration  of  nutiition  in  the  coats  of  the  capillaries 
and  smaller  blood-vessels,  so  that  they  rupture  readily  under  the  pressure 
of  the  blood.  This  explanation  may  be  a  sufficient  one  when  the  purpura 
occurs  in  a  cachectic  subject,  but  it  cannot  apply  to  the  sudden  tendency 
to  hemorrhages  often  manifested  by  a  child  whose  health  had  been  pre- 
viously satisfactory.  Henoch  suggests  that  in  these  cases  the  cause  of  the 
effusion  may  be  a  vaso-motor  neurosis  which  gives  rise  to  stasis  in  the 
blood,  rupture  of  the  wall  of  the  capillaries,  or  migi-ation  of  the  blood 
globules  from  paralytic  dilatation  of  the  smallest  vessels. 

Symj^toms. — The  spots  may  appear  quite  suddenly  without  previous 
signs  of  ill-health.  Often,  however,  they  are  preceded  by  more  or  less 
aching  of  the  limbs,  shght  feverishness,  thu-st,  and  symptoms  of  indiges- 
tion. The  child  has  no  a^Dpetite  and  is  unwilling  to  exert  himself,  crjing 
if  obUged  to  walk,  and  complaining  constantly  of  feehng  tu-ed.  In  some 
cases  the  appearance  of  the  purpuiic  rash  follows  an  attack  of  vomiting 
and  diarrhcea.  The  spots  ai-e  cii-cular  and  of  a  brick-red  or  deep  purple 
colour.  They  are  not  elevated  above  the  surface,  and  XDressnre  does  not 
cause  them  to  disappear.  In  size  they  vary  from  a  pin's  head  to  the 
diameter  of  half  an  inch  or  more,  and  their  outline  is  distinctly  defined. 
They  may  be  so  closely  set  as  to  be  confluent.  This  is  especially  common 
about  the  instep  and  ankles.  Often  they  are  accompanied  by  marks  like 
bruises  due  to  extravasation  into  the  subcutaneous  tissue.  These  are 
bluish  discolourations  without  defined  margin,  and  may  be  accompanied 
by  some  sweUing.  They  appear  to  be  sometimes  the  consequence  of  in- 
significant injuries,  for  a  gentle  pinch  or  feeble  blow  will  produce  them. 
The  purpuiic  spots  come  out  in  successive  crops,  and  each,  after  going 
thi'ough  the  ordinaiy  changes  of  colour-  peculiar  to  such  haemon-hages, 
disappears  in  the  course  of  a  few  days.  At  times  the  skin  will  be  found 
to  be  nearly  clear  ;  then  another  crop  is  discovered  and  the  surface  is 
thickly  studded  with  them  as  before.  They  are  usually  most  numerous 
on  the  hmbs,  but  are  found  besides  on  the  trunk,  and  sometimes,  although 
rai-ely,  on  the  face.  Mixed  up  with  the  true  piuiDiuic  spots  may  be 
wheals   of  urticaria,  httle  patches  of  erji;hema  papidatum  or  eiythema 


PUEPUEA — SYMPTOMS.  249 

nodosum,  and  occasionally  blebs  arise  filled  with  bloody  serum.  Inspec- 
tion of  the  mouth  will  also  often  discover  minute  hsemorrhagic  extravasa- 
tions into  the  mucous  membrane  of  the  lips  and  cheeks. 

In  the  more  acute  form  of  the  disease,  when  the  general  health  has 
been  previously  satisfactory,  the  pur^Duric  spots  may  be  accompanied  by 
cedematous  swelling.  The  hmbs  then  feel  unusually  firm  and  full  and  pit 
on  pressure.  Unless  haemorrhage  occurs  from  the  ruinary  passages  there 
is  no  albuminuria. 

A  healthy  little  girl,  aged  five  years,  began  to  lose  her  appetite  and 
complain  of  pains  in  the  legs  and  knees.  She  was  unwilling  to  take  ex- 
ercise, and  after  walking  for  a  short  distance  would  say  that  her  legs 
ached  and  ask  to  be  carried  up-stairs.  These  symptoms  continued  for 
two  or  three  weeks  without  improvement.  The  child  then  became  slightly 
feverish,  her  knees  swelled,  and  purpuric  spots  appeared  on  the  lower  part 
of  the  body  and  on  the  legs.  When  seen  on  the  sixth  day  the  child  looked 
well  in  the  face  and  seemed  cheerful.  The  spots  were  numerous  on  the 
lower  hmbs  and  varied  from  a  pea  to  a  fourpenny  bit  in  size.  They  were 
brick-red  in  colour  with  a  well-defined  outhne,  and  did  not  disappear  on 
pressure  with  the  finger.  In  addition  to  these  spots  there  were  larger 
patches,  like  bruises,  of  a  greenish  or  yellowish  colour.  Both  legs  were 
uniformly  swollen  and  felt  very  firm.  They  pitted  distinctly  on  firm 
pressure.  The  knees  were  not  swoUen  or  tender  at  this  time,  but  were 
said  to  have  been  very  tender  and  painful.  The  skin  covering  the  pop- 
hteal  spaces  was  much  ecchymosed.  There  had  been  no  bleeding  from 
the  nose  or  other  mucous  tract.  The  heart-sounds  were  healthy.  There 
was  no  albumen  in  the  urine. 

The  pains  in  the  Umbs  usually  continue  after  the  spots  have  appeared, 
but  subside  in  a  few  days.  A  return  of  the  pain  is  sometimes  found  to 
precede  the  eruption  of  each  successive  crop  of  spots.  The  number  of 
the  crops  varies.  Sometimes  there  is  only  one.  Usually,  however,  they 
are  more  numerous.  Exercise  seems  to  encourage  the  hsemorrhages,  and 
rest  is  therefore  an  important  element  in  the  treatment.  In  the  simple 
form  the  disease  is  usually  at  an  end  in  from  one  to  three  weeks. 

In  simple  purpura  the  extravasations  are  hmited  to  the  skin,  but  in 
ihe  more  severe  form,  called  hcemorrhagic  purpura,  effusions  of  blood  are 
noticed  from  other  parts.  The  nose  bleeds,  and  the  haemorrhage  may  be 
so  copious  that  it  has  to  be  arrested  by  mechanical  means.  Blood  may  be 
also  discharged  from  the  eyehds,  the  gums,  the  ears,  the  lungs,  the 
stomach,  the  bowels,  and  the  kidneys.  Hsematuria  is  a  common  conse- 
quence of  hjcmorrhagic  purpura,  and  the  amount  of  blood  may  be  so 
copious  from  this  soiu-ce  that  the  urine  passed  is  of  a  deep  red  colour. 
The  renal  hsemorrhage  often  occurs  in  one  gush  and  then  ceases  enthely 
ior  a  time,  so  that  two  successive  discharges  from  the  bladder  may  be  of 
quite  different  characters — the  first  blood  red,  the  second  perfectly  limpid 
and  normal  in  appearance.  Still,  even  if  there  be  no  naked-eye  signs  of 
blood  in  the  water,  the  microscope  will  sometimes  detect  red  corpuscles  in 
the  deposit.  Heemorrhage  from  the  bowels  is  seen  as  black  clots  at  the 
bottom  of  the  chamber-pan.  It  is  rarely  copious.  Its  appearance  may  be 
preceded  by  severe  abdominal  pain,  which  ceases  when  the  blood  is  dis- 
charged from  the  bowels.  Sometimes  colicky  pain  occurs  without  being 
followed  by  intestinal  hsemorrhage. 

When  pains  in  the  joints  are  complained  of,  there  may  be  some  ten- 
derness and  considerable  swelling.  This  symptom  is  often  spoken  of  as 
"rheumatism,"  and  the  disease  is  then  called  purpura  rheumatica.      It 


250  DISEASE   IN   CHILDRElSr. 

seems  probable,  however,  tliat  sometimes,  at  any  rate,  tlie  lesion  is  due  not 
to  rheumatic  inflammation  but  to  haemorrhage  into  or  around  the  joint.  If 
it  arise  from  this  cause  the  articular  affection  is  more  chronic  than  a 
rheumatic  joint  lesion,  and  remains  confined  to  the  part  first  attacked. 
There  is  no  necessary  discolouration  of  the  skin. 

During  the  progress  of  the  complaint  the  general  symptoms  are  often 
indefinite.  The  appetite  may  be  good  or  more  or  less  impaired.  A  cer- 
tain amount  of  thirst  is  usually  to  be  noticed.  The  liver  may  become 
much  swollen  from  congestion,  and  the  bowels  are  often  confined.  Usually, 
until  the  loss  of  blood  has  produced  anaemia,  the  child  complains  only  of 
aching  and  feeling  tired.  The  temperature  is  often  normal,  but  sometimes 
there  is  irregular  pyrexia.  The  febrile  heat  does  not,  however,  appear  to 
bear  any  relation  to  the  haemorrhage.  I  have  not  found  it  to  precede  or 
follow  in  any  regular  manner  the  flow  of  blood. 

A  robust  little  boy,  six  years  of  age,  was  in  his  usual  health  when  he 
suddenly  began  to  bleed  from  the  eyes,  nose,  and  mouth.  During  the  next- 
month  he  continued  to  bleed  every  morning  from  the  gums,  and  on  three 
separate  occasions  had  copious  attacks  of  haemorrhage  from  the  eyes  and 
nose.  An  accidental  cut  on  the  finger  also  bled  profusely  for  two  hours. 
During  all  this  month  the  boy  was  very  thirsty,  drinking  any  fluid  he 
could  get,  even  dirty  water. 

On  admission  into  the  East  London  Children's  Hospital  the  child 
seemed  to  be  well  nourished  and  had  a  healthy  appearance,  with  a  fair 
amount  of  colour  in  his  face.  His  gums  were  not  sj)ongy.  His  face,  body, 
and  limbs  were  thickly  covered  with  purpuric  spots  of  a  brownish-red 
colour,  which  did  not  fade  on  pressure.  There  were  in  addition  large 
bruises  on  the  right  arm,  the  trunk,  and  the  left  thigh.  There  was  no 
enlargement  of  the  liver  or  spleen.  The  urine  had  a  density  of  1.029.  It 
was  clear,  without  sediment,  and  contained  no  albumen.  The  heart  beat 
in  the  fifth  interspace  in  the  nipple  line.  At  the  apex  the  sounds  were 
healthy  but  muffled,  and  a  loud  anaemic  murmur  was  heard  at  the  base. 

While  in  the  hospital  the  patient  had  frequent  haemorrhages  from  the 
nose,  the  mouth,  the  bowels,  the  kidneys,  and  into  the  skin.  On  one  oc- 
casion he  repeatedly  retched  and  vomited  large  black  clots  of  blood.  He 
also  complained  much  of  abdominal  pain,  and  passed  large  quantities  of 
black  blood  from  the  bowels.  This  may,  of  course,  have  been  blood 
poured  out  by  the  nasal  fossae  and  swallowed  ;  but  the  haemorrhage  was  at. 
any  rate  copious,  and  caused  a  marked  blanching  of  the  skin  and  much 
feebleness  and  languor.  The  boy's  temperature  varied  considerably  dur- 
ing his  illness.  He  had  irregular  attacks  of  fever  during  which  the  tem- 
perature would  rise  to  101°  or  even  higher,  but  the  pyrexia  did  not  always 
precede  the  gush  of  blood.  If,  however,  there  was  fever  when  the  haemor- 
rhage occurred,  the  first  effect  of  the  flow  was  to  reduce  the  bodilj''  heat 
to  a  subnormal  level. 

The  boy  was  treated  first  with  iron,  which  seemed  to  have  no  effect 
upon  the  haemorrhages  ;  then  with  aperients,  which  produced  at  first  a. 
marked  improvement ;  later  with  iron  and  arsenic  combined,  under  which 
he  became  rapidly  convalescent. 

When  anaemia  occurs,  the  ordinary  signs  of  debility  are  noticed.  The 
child  is  pallid  and  feeble.  He  is  restless  and  complains  of  headache,  and 
his  pulse  is  frequent  and  irritable.  A  systolic  murmur  can  usually  be  de- 
tected at  the  base  of  the  heart,  and  a  loud  venous  hum  is  not  uncom- 
monly heard  at  the  upper  part  of  the  sternum. 

There  may  be  some  oedema  of  the  ankles,  and  even  of  the  limbs  and 


PURPUKA — SYMPTOMS — TREATMENT.  251 

face.  In  very  severe  forms  of  the  disease  the  child  may  die  from  syncope 
or  exhaustion,  and  sometimes  death  occurs  in  an  attack  of  convulsions. 
Convulsions  are  due  in  rare  cases  to  haemorrhage  into  the  cranial  cavity. 
Mi\  Hallowes  has  reported  the  case  of  a  boy  between  three  and  four  years 
old,  who  had  Uved  in  a  good  air  and  been  well  fed.  This  lad,  after  being- 
languid  for  one  day,  developed  bruise-like  patches  on  different  parts  of 
the  body,  and  died  on  the  third  day  after  a  convulsive  attack  followed  by 
rigidity.  At  the  autopsy  extensive  hsemon-hage  was  found  to  have  oc- 
curred into  both  ventricles  with  laceration  of  the  brain  substance.  No  rup- 
tured vessel  could  be  found. 

Convulsions  in  purpura  are  not  always  the  consequence  of  cerebral 
haemorrhage.  A  httle  girl  three  months  old  was  under  my  care  in  the 
East  London  Children's  Hospital  for  vomiting  and  diarrhoea.  After  these 
derangements  had  ceased  a  purpuric  eruiDtion  developed  on  the  body,  and 
in  a  few  days  the  child  had  an  attack  of  convulsions  and  died.  Here  the 
brain  was  found  to  be  unusually  anaemic,  and  there  were  no  signs  of  intra- 
cranial extravasation.  These  are,  however,  exceptional  cases.  In  the 
child  a  fatal  termination  to  the  illness  is  rare.  Usually  after  a  longer  or 
shorter  period  the  haemorrhages  cease,  and  the  patient  regains  his  colour 
and  strength. 

The  course  of  the  disease  is  almost  always  irregular.  The  successive 
crops  occur  at  uncertain  intervals,  and  often  the  disease  is  thought  to  be 
cured  when  a  sudden  return  of  the  extravasations  shows  us  that  the  haem- 
orrhagic  tendency  is  not  yet  overcome. 

Diagnosis. — Haemorrhagic  purpura  cannot  be  confounded  with  a  ma- 
lignant form  of  exanthema,  for  the  high  fever  and  profound  general  suf- 
fering manifested  in  such  dangerous  cases  are  not  present  in  the  milder 
complaint. 

In  scurvy  there  is  always  a  history  of  privation  or  injudicious  feeding  ;. 
the  special  symptoms  follow  upon  a  period  of  ill-health ;  general  tender- 
ness is  a  prominent  feature  ;  and  there  is  marked  feebleness  fi-om  the  very 
first.  In  all  these  points  the  affection  differs  from  purpura.  Moreover,  the 
treatment  of  the  two  diseases  is  different,  and  measures  which  are  found 
to  have  an  immediate  influence  upon  the  scorbutic  condition  are  powerless- 
■^o  check  the  haemorrhagic  tendency  in  purpura. 

In  haemophilia,  which  is  characterised  by  similar  symptoms  to  those 
of  purpura,  the  disease  is  a  constitutional  one  and  is  almost  always  hered- 
itary ;  the  family  tendency  is  well  recognised,  and  the  haemorrhage  is. 
usually  first  manifested  as  a  consequence  of  a  cut  or  injury.  Moreover, 
the  disposition  to  bleed  is  a  chronic  and  permanent  state,  and  is  not  a. 
more  or  less  acute  condition  which  can  be  made  to  cease  by  appropriate 
remedies. 

Prognosis. — In  simple  uncomplicated  purpura  the  prognosis  is  always. 
favourable.  In  haemorrhagic  purpura  the  disease  is  more  serious  ;  but 
if  the  child  be  submitted  early  to  treatment  the  illness  rarely  has  a  fatal 
issue. 

Treatment. — In  all  cases  of  purpura  the  child  should  be  confined  to 
his  bed,  as  rest  is  of  extreme  importance  in  preventing  repeated  relapses 
of  the  disease.  The  two  forms  of  purpura,  viz,,  that  which  comes  on 
quite  suddenly  in  healthy  children  and  that  which  attacks  feeble  or  cachec- 
tic subjects,  require  a  different  method  of  treatment.  In  the  first  the 
old  plan  of  energetic  purgation  is  peculiarly  valuable.  Often  in  such  cases 
a  course  of  iron  or  other  tonic  is  followed  by  no  benefit  whatever,  while  a, 
few  doses  of  some  di-astic  aperient  cause  a  prompt  and  final  disappearance-- 


252  DISEASE   IX   CHILDEE2T. 

of  all  haemorrliagic  symptoms.  TMs  treatment  is  equally  useful  -whether 
the  complaint  be  of  the  simple  or  heemorrhagic  variety,  and  may  be  em- 
ployed without  fear  even  in  cases  where  great  ansemia  has  been  induced 
by  the  loss  of  blood.  If  the  hver  is  found  to  be  swollen  from  congestion, 
as  sometimes  happens,  its  size  is  quickly  reduced  by  the  purging.  It  is  in 
these  cases,  perhajDS,  that  the  value  of  aperients  is  most  strikingly  illustra- 
ted ;  but  all  cases  of  the  acute  variety  of  the  complaint  seem  to  be  bene- 
fited by  this  method  of  treatment.  The  best  foi-m  in  which  the  aperient 
can  be  prescribed  is  a  combination  of  the  oil  of  tui-pentine  with  castor-oil. 
For  a  child  six  years  old,  two  drachms  of  each  may  be  given  made  into 
an  emulsion  with  mucilage  of  tragacanth  and  flavoru'ed  with  symp  of 
lemons  and  peppermint  water.  This  draught  should  be  taken  before  break- 
fast every  morning,  or  on  alternate  mornings,  according  to  the  effect  pro- 
duced. If  the  heemorrhage  is  not  aiTested  in  the  course  of  a  few  days,  ii'on 
and  arsenic  should  be  given  in  addition  after  each  meal.  A  child  of  this  age 
will  take  without  inconvenience  fifteen  di'ops  of  the  tincture  of  perchloride 
of  iron  and  thi^ee  or  four  of  Fowler's  solution,  freely  diluted,  three  times  a 
day.  Other  treatment  is  also  recommended.  Werlhof,  who  fii'st  described 
the  disease,  relied  upon  cjuinine  and  dilute  sulphiiric  acid.  Ergot  is  j)i'e- 
ferred  by  some,  especially  in  cases  where  the  hccmorrhages  are  copious  ; 
but  this  drug  should  be  always  given  by  the  mouth  and  never  hypodermi- 
cally  by  the  injection  of  a  solution  of  ergotin,  as  obstinate  bleeding  has 
been  known  to  result  from  the  jDuncture  of  the  needle. 

Special  hsemorrhages  must  be  treated  by  special  means  :  epistaxis  by 
the  injection  of  iced  water,  or  by  the  use  of  a  sj^ray  of  perchloride  of  ii'on. 
In  using  the  spray  the  nasal  passages  must  be  iu'st  cleared  out  completely 
of  clot  by  the  injection  of  water.  Aftei-wai'ds  two  drachms  of  the  strong 
perchloride  of  ii'on  solution  diluted  with  water  to  two  ounces  must  be 
sprayed  into  the  nostiils.  HtemoiThage  from  the  gums  may  be  usually 
aiTCsted  by  an  alum  gargle  or  the  infusion  of  rhatany  ;  intestinal  haemor- 
rhage by  iced-water  injections  and  the  apphcation  of  an  ice-bag  to  the  ab- 
domen.    In  hgematuria  gallic  acid  should  be  given. 

"When  the  patient  becomes  anemic,  stimulants  (port  wine  or  the  St. 
Eaphael  tannin  -wine)  must  be  given,  and  the  child  should  take  plenty  of 
nutritious  food. 

In  the  cachectic  form  of  pui'pui'a  aperients  are  less  suitable.  In  these 
cases  stimulants  are  required  h'om  the  fii'st,  and  the  child  should  take 
food  in  smaU  quantities  at  a  time  so  as  not  to  overtask  his  feeble  digestive 
powers.  Iron  viine  may  be  given  with  ai'senic,  and  cod-hver  oil  is  useful. 
As  a  special  st}-ptic  tui-pentine  in  ten-minim  doses  is  of  sei-vice,  taken 
every  three  or  four  houi's,  or  an  equal  c[uantity  of  the  hquid  exti'act  of  ergot 
may  be  administered  several  times  in  the  day. 


CHAPTER  YIL 

SCURVY. 

ScuEVY  is  a  disease  wliich  is  now  rarely  seen  in  its  most  pronounced  form 
even  in  the  adult,  unless  under  circumstances  of  exceptional  hardship  and 
privation.  As  one  of  the  diseases  to  which  young  children  are  liable  it 
has  been,  until  recent  times,  completely  ignored.  Lately,  however,  owing 
to  the  observations  of  Drs.  Cheadle,  Gee,  T.  Barlow,  and  others,  a  form  of 
the  malady  has  been  recognised  as  an  occasional  consequence  in  infants 
of  bad  feeding  and  injudicious  management.  In  such  siibjects  the  disease 
is  commonly  grafted  upon  rickets  ;  and  there  can  be  little  doubt  that  it  is 
this  conjunction  of  the  two  maladies  which  constitutes  the  state  described, 
by  Fiirst  and  others  under  the  name  of  acute  rickets. 

Causation. — A  scorbutic  taint  which  reveals  itseH  by  the  milder  phe- 
nomena of  scurvy  appears  to  be  less  uncommon  than  was  at  one  time  sup- 
posed amongst  the  out-patients  of  large  hospitals.  Dr.  Eade,  of  Norwich, 
and  Dr.  Ralfe,  of  the  London  Hospital,  have  both  met  with  such  cases 
amongst  their  patients  ;  and  Surgeon-General  Moore  has  remarked  upon 
the  frequency  with  which  similar  symptoms  can  be  detected  amongst  the 
inhabitants  of  certain  districts  in  India.  In  all  such  cases  bad  or  insujBi- 
cient  food  is  no  doubt  the  cause  of  the  impoverished  state  of  the  system, 
especially  the  want  of  fresh  meat,  fresh  milk,  potatoes,  and  vegetables 
generally.  In  young  children  the  causes  appear  to  be  veiy  similar  to  those 
which  have  the  power  of  setting  up  rickets,  although  they  are  not  identi- 
cal with  them.  If  an  infant  be  fed  with  excess  of  starchy  food  and  sup- 
jjlied  with  sweetened  preserved  milk  instead  of  the  fresh  mUk  of  the  cow  ; 
if  he  be  dirty  and  neglected  as  to  his  person,  and  breathe  habitually  a 
close,  foul  air,  the  conditions  are  just  those  which  are  capable  of  setting 
,up  the  scorbutic  state.  An  infant  so  brought  up  quickly  begins  to  show 
signs  of  rickets,  and  may  perhaps  be  found  all  at  once  to  develop  the 
symptoms  of  scurvy.  That  every  badly  fed  child  does  not  manifest  similar 
phenomena  is  probably  owing  to  the  fact  that  many  articles  of  diet  are 
anti-scorbutic,  although  not  anti-rachitic  ;  indeed  some,  while  they  pre- 
serve from  scurvy,  may  actually  aid  in  the  production  of  rickets.  Scur-s-y 
differs  from  rickets  in  not  being  a  disease  of  general  malnutrition.  In 
the  former  the  affection  is  due  merely  to  the  absence  from  the  blood  of 
some  constituent  whose  presence  is  essential  to  health.  In  the  latter  the 
whole  system  suffers,  and  the  condition  is  one  of  general  impairment  of 
nutrition  from  deficiency  of  wholesome  food.  Consequently  as  long  as 
the  indispensable  element  is  suppKed  to  the  blood  the  patient  does  not  be- 
come scorbutic,  however  well  the  diet  may  be  adapted  to  favour  the  oc- 
currence of  rickets.  Thus  a  child  fed  largely  upon  potatoes  may  very 
probably  grow  rickety,  but  he  will  certainly  escajDe  scui-vj^  Again,  in  Eng- 
land fx'esh  fruit,  being  cheap,  is  largely  consumed  by  the  children  of  the 
poor.     Even  babies  in  arms  are  allowed  to  nibble  at  an  apple  or  a  plum 


^54  DISEASE   IF   CHILDEEIS". 

as  soon  as  they  are  able  to  hold  an  object  in  their  hands.  During  the 
summer  months  they  get  strawberries  and  gooseberries  ;  in  the  au- 
tumn apples,  pears,  and  plums  ;  and  in  the  winter  and  spring  oranges. 
By  such  means  a  scorbutic  tendency  is  no  doubt  counteracted,  but  general 
nutrition  is  little  improved  ;  indeed,  it  is  not  improbable  that  on  account 
of  the  indigestion  and  acidity  which  such  indrdgences  must  necessa- 
rily excite  at  this  early  age  the  occurrence  of  rickets  is  actually  pro- 
moted. 

The  outbreak  of  scurvy  often  appears  to  be  determined  by  some  influ- 
ence which  causes  a  temj)orary  depression  in  the  child's  strength.  Chil- 
dren who  inherit  a  diathetic  tendency  are  probably  more  prone  than 
constitutionally  healthy  subjects  to  suffer  readily  from  the  want  of  milk 
and  fresh  and  wholesome  food.  In  many  cases,  however,  it  is  noticed  that 
the  jpatient  is  enabled  to  resist  for  a  long  time  the  influence  of  a  distinctly 
injurious  dietary  ;  and  it  is  only  when  the  nutritive  processes  are  brought 
to  a  sudden  standstill  by  an  attack  of  gastro-intestinal  catarrh  that  scorbu- 
tic symptoms  begin  to  be  observed. 

Scurvy  is  not  confined  to  the  subjects  of  rickets,  but  most  scorbutic 
children  are  found  to  be  suffering  from  that  disease.  This  is  not  to  be 
wondered  at,  for  the  age  at  which  lickets  is  most  liable  to  occur  is  also 
that  at  which  scurvy  is  chiefly  found  to  prevail.  The  two  affections  are 
also,  as  has  been  said,  induced  by  causes  very  similar  in  kind  ;  and  the 
general  impairment  of  nutrition  of  which  rickets  is  the  consequence  no 
doubt  renders  the  patient  especially  sensitive  to  the  effects  of  a  scurvy 
diet.  In  most  of  the  recorded  cases  of  scurvy  in  the  young  subject  the 
jjatients  have  been  under  eighteen  months  old. 

3Iorhid  Anatomy. — One  of  the  most  characteristic  morbid  changes  in- 
duced by  the  disease  is  a  copious  extravasation  of  blood  into  the  tissues 
of  the  limbs,  especially  of  the  thighs.  The  muscles  themselves  are  usu- 
ally pale,  but  the  tissues  between  them  may  be  infiltrated  with  serum 
more  or  less  blood-stained.  Sometimes  blood  is  extravasated  into  the 
substance  of  the  muscles,  but  without  any  e\ident  laceration  of  the  fibres. 
The  chief  seat  of  the  extravasation  is  between  the  periosteum  and  the  bone. 
In  many  cases  the  investing  membrane  is  foiuid  to  be  separated  widely 
fi'om  the  shaft  of  the  bone,  retaining  its  attachment  merely  at  the  epi- 
physes. It  is,  moreover,  greatly  thickened  and  deeply  injected.  Between 
it  and  the  bone  lies  a  large,  loosely  adherent  blood-clot  in  which  the  bone 
is  embedded.  "When  the  clot  is  cleared  away  the  bone  is  found  to  be 
perfectly  smooth,  although  bare  of  periosteum.  Another  common  feature 
is  a  separation  of  the  epiphyseal  ends  of  the  long  bones.  This  separation 
is  not  at  the  line  of  union  of  the  epiphysis,  but  in  the  shaft  of  the  bone 
just  below  the  point  of  junction.  The  osseous  structui-e  at  the  seat  of 
fracture  can  be  noticed  to  be  particularly  loose  and  spongy.  It  is  impor- 
tant to  remark  that  in  all  these  cases  where  separation  of  periosteum  has 
occurred  no  sign  of  caries  or  exfoliation  of  the  bone  is  to  be  discovered. 
Nor  does  the  extravasation  of  blood  ever  appear  to  end  in  suppui-ation. 
The  shaft  of  the  bone  is  curiously  fi-agile  and  thinned.  This  atrophy  is 
well  seen  in  some  cases  in  the  ribs,  which  may  appear  to  be  reduced  to 
the  two  bony  plates  by  almost  complete  loss  of  their  cancellous  structure. 
Extravasation  of  blood  never  seems  to  take  place  into  the  articulations,  as 
is  seen  in  hsemophiha  ;  for  all  the  joints  and  tissues  immediately  connected 
with  them  are  found  to  be  healthy. 

The  above  changes  in  the  bones  and  periosteum  are  common  to  aU  fatal 
cases  of  scurvy  in  the  child.     Mr.  T.  Smith's  case  exhibited  at  the  Pathc 


SCURVY — MORBID   ANATOMY — SYMPTOMS.  255 

logical  Societ}'-  of  London  in  1875-76,  under  the  provisional  name  of 
"  hgemorrliagic  periostitis,"  showed  the  above  changes  in  both  lower  hmbs. 
The  parts  principally  involved  were  the  thigh  bones,  but  the  bones  of  the 
legs  were  affected,  although  to  a  less  extent.  In  Dr.  T.  Barlow's  beautifiil 
preparations  shown  at  the  Eoyal  Medical  and  Chirurgical  Society  in  1883, 
the  same  characters  were  obseiwed.  The  effased  blood  has  usually  been 
found  of  a  deep  marone  colour  and  coagulated.  Of  other  organs  the  ab- 
dominal viscera  are  generally  healthy  in  these  cases.  The  same  thing  may 
be  said  of  the  chest ;  but  once  or  twice  Dr.  Barlow  has  found  some  effusion 
in  the  cavity  of  the  jDleura,  and  in  ]\Ir.  T.  Smith's  case  there  was  a  small 
haemorrhage  in  the  lung.  Often  no  sponginess  or  inflammation  of  the 
gums  is  to  be  seen,  but  little  haemorrhages  have  been  noticed  at  the  point 
of  t]ie  gum  in  the  situation  of  the  up-coming  teeth.  Other  small  extravasa- 
tions may  be  present  in  the  skin  in  various  parts  of  the  body.  They  may 
occur  around  the  ribs,  and  may  be  discovered  in  the  intestines  and  kidney. 

The  above  morbid  characters  can  leave  Httle  doubt  that  these  cases  are 
rightly  classed  under  the  head  of  scurvy.  It  has  been  objected  to  this 
view  that  although  the  symptoms  observed  during  the  life  of  the  child  do 
not,  as  a  rule,  point  to  any  very  marked  deterioration  in  the  quality  of  the 
blood,  the  lesions  noted  after  death  are  the  later  manifestations  of  the  dis- 
ease, such,  indeed,  as  occur  in  the  adult  only  as  a  consequence  of  profound 
constitutional  cachexia.  Thus  sub-periosteal  haemorrhage,  which  is  a  late 
symptom  in  the  adult,  is  produced  early  in  the  child ;  and  the  affection  of 
the  gums,  which  is  usually  regarded  as  one  of  the  earliest  and  most  charac- 
teristic symptoms  of  scurvy,  may  be  absent  in  the  young  subject  altogether. 
To  this  it  may  be  rephed  that  cachexia  is  produced  very  rapidly  in  the 
infant  by  acute  disease,  and  that  in  some  cases  of  sciu'vy  in  the  child  an  ex- 
treme degTee  of  anaemia  and  debility  has  been  reached.  But  granting  that  in 
many  cases  serious  lesions  have  been  discovered  where  the-  general  symp- 
toms have  been  comparatively  mild,  this  is  not  to  be  wondered  at,  consider- 
ing the  age  and  peculiarities  of  the  patient.  In  a  blood  disease  such  as 
scurvy  it  might  almost  be  anticipated  that  the  tissues  chiefly  affected 
would  be  those  in  which  growth  and  development  are  making  most  active 
jDrogress.  At  the  age  at  which  young  infants  are  usually  foimd  to  suffer  no 
tissues  or  organs  are  undergoing  more  rapid  changes  than  the  long*  bones, 
especially  those  of  the  lower  limbs  ;  and  it  is  exactly  in  these  situations 
that  the  more  pronounced  lesions  are  observed.  On  the  other  hand,  in  the 
maxillary  bones  ossification  and  development  are  practically  at  a  standstill ; 
for  the  child  being  (as  he  almost  always  is)  the  subject  of  rickets,  the  jaws 
have  ceased  for  the  time  to  increase  in  size,  and  the  evolution  of  the  teeth 
is  completely  arrested. 

The  cause  of  the  deterioration  of  the  blood  in  scin'vy  appears  to  be, 
not  the  mere  absence  of  potash  salts,  as  Dr.  Garrod  beHeved,  but  rather, 
as  Dr.  Buzzard  supposes,  the  absence  of  these  salts  in  combination  with 
organic  acids.  Dr.  Ralfe  has  still  fiu'ther  developed  the  latter  hypothesis. 
This  observer  is  of  opinion  that  the  primary  change  depends  on  a  general 
want  of  normal  proportion  between  "the  various  acids,  inorganic  as  well 
as  organic,  and  bases  found  in  the  blood,  by  which  the  neutral  salts,  such 
as  the  chlorides,  are  either  increased  relatively  at  the  expense  of  the  alka- 
hne  salts "  or  these  latter  are  absolutely  decreased.  He  concludes  that 
there  is  a  diminution  in  the  alkalinity  of  the  blood,  and  that  this  produces 
dissolution  of  the  blood-coi-puscles  and  fatty  degeneration  of  the  muscles 
and  of  the  secreting  cells  of  the  liver  and  kidneys. 

Symjjtoms. — Children  in  whom  the  symptoms  of  scurvy  are   noticed 


256  DISEASE  IjS"   CHILDEEN. 

are  often  large,  flabby  infants  between  twelve  and  eighteeii  months  old. 
They  usually  show  the  milder  phenomena  of  rickets,  such  as  profuse 
sweating  about  the  head,  lateness  of  dentition,  enlargement  of  the  ends  of 
the  long  bones,  and  beading  of  the  ribs.  In  such  subjects  the  course  of 
the  scorbutic  disease  is  as  follows :  The  patient  shows  signs  of  unusual 
and  extreme  tenderness.  He  dreads  being  handled,  cries  if  put  upon  his 
feet,  and  if  he  had  been  able  to  walk,  is  qxiite  taken  off  his  legs.  Next  he 
begins  to  suffer  from  pains  which  seem  to  be  constant.  The  child  lies 
moaning  in  his  cot,  and  screams  if  touched  or  even  approached.  Veiy 
soon  swelHng  is  noticed  of  a  hmb,  usually  a  thigh — one  or  both.  The 
affected  part  is  enlarged  by  a  cylindiical  swelling  which  although  not  ac- 
tually brawny  to  the  touch  is  yet  firmer  than  natural.  In  many  cases  it  is 
distinctly  cedematous,  but  it  may  not  pit  imder  the  finger,  although  it 
often  gives  the  sensation  of  containing  infiltrated  serosity.  In  the  lower 
limb  the  swelling  usually  occupies  the  whole  length  of  the  thigh  and  often 
of  the  leg.  There  is  no  perceptible  fluctuation,  and  no  enlarged  veins 
can  be  seen,  but  the  tint  of  the  skin  is  often  hvid  or  faintly  lead-coloured, 
and  in  a  case  recorded  by  Fiirst  its  tint  was  red  and  ghstening.  There  is 
no  effusion  into  the  joints,  but  these  are  usually  swollen  from  enlargement 
of  the  articular  ends  of  the  bones.  The  upper  limbs  are  less  affected  than 
the  lower.  The  forearm  just  above  the  wiist  is  here  the  part  in  which 
swelling  is  most  commonly  noticed.  In  such  a  case  if  the  swelling  is  not 
extensive,  it  is  difiicult  to  distinguish  it  fi'om  the  ordinary  epiphyseal  en- 
largement so  commonly  present  in  the  rickety  child.  But  besides  the 
parts  which  have  been  mentioned,  swellings  from  local  periosteal  extra- 
vasation may  be  found  at  the  upper  part  of  the  humerus  and  on  the 
shoulder-blades,  and  sometimes  similar  extravasations  are  noticed  in  the 
skin  and  subcutaneous  tissue.  Petechiee,  bruise-like  patches,  and  even 
small  blood-tumours  may  be  met  with.  There  appears  also  to  be  the 
same  tendency  to  the  foiTnation  of  ulcei-ating  sores  on  the  cutaneous  sur- 
face which  has  been  remarked  in  cases  of  scurvy  affecting  the  adult.  In 
one  of  Dr.  Cheadle's  cases — a  httle  boy  aged  sixteen  months — there  were 
two  unhealthy  looking  sores  seated  the  one  on  the  right  wrist,  the  other 
on  the  fore-fiiger. 

At  first,  when  the  swellings  begin,  the  child  keeps  his  limbs  flexed,  but 
later  a  new  phenomenon  is  noticed.  The  patient  ceases  to  flex  his  legs, 
and  allows  them  to  remain  stretched  out  straight  in  the  bed,  as  if  he  had 
lost  all  power  of  movement.  It  will  now  be  noticed  on  examination  that 
a  soft  crepitus  can  be  detected  in  the  neighbourhood  of  the  joints  from 
separation  of  the  epiphyseal  ends  of  the  bones,  and  the  wi'ist  may  drop 
from  fracture  of  the  carpal  end  of  the  radius.  At  this  stage  the  joints 
can  be  examined  without  the  child  appearing  to  suffer  pain  from  the  moye- 
ment  of  the  articulations. 

In  many  of  the  cases  in  which  the  symptoms  are  well  marked,  spongi- 
ness  of  the  gums  and  other  minor  manifestations  of  the  scorbutic  taint  are 
entirely  absent.  Sometimes,  however,  the  gums  are  red  and  soft  and 
gelatinous-looking,  and  may  be  so  swollen  as  actually  to  proti-ude  between 
the  patient's  hps.  They  bleed  at  the  least  touch.  The  swelling  may  ex- 
tend to  the  mucous  membrane  of  the  palate,  and  this  may  be  so  spongy  as^ 
almost  to  touch  the  dorsum  of  the  tongnie  when  the  mouth  is  open  Dr. 
Cheadle  has  reported  some  cases  in  which  the  affection  of  the  gums  was 
imaccompanied  by  signs  of  deep-seated  extravasation  m  the  limbs,  but  the 
two  conditions  may  be  present  together.  The  child  appears  at  this  time 
to  be  the  subject  of  marked  cachexia.     He  is  sallow  and  veiy  emaciated ; 


SCURVY — SYMPTOMS — DIAGNOSIS.  257 

his  temperature  is  often  raised,  reaching  to  101°  or  102°  in  the  evening  ; 
his  appetite  is  poor,  and  his  bowels  may  be  relaxed.  Often  profuse  per- 
spirations are  noticed.  If  the  raucous  membrane  of  the  mouth  or  gums 
is  affected,  the  breath  has  a  most  offensive  odour.  The  weakness  is  usu- 
ally very  great.  The  child  ceases  to  be  able  to  support  himself  in  a  sit- 
ting posture,  and  when  placed  in  that  position  falls  on  to  his  side  at  once 
if  left  alone.  The  urine  may  contain  albumen  and  sometimes  is  reddened 
with  blood.  The  abdominal  organs  seem  to  be  healthy,  and  no  enlarge- 
ment can  be  detected  of  the  liver  or  spleen.  There  may  be  cough,  but  the 
physical  signs  of  the  chest  are  usually  normal,  or  consist  merely  in  a  few 
large  bubbles  heard  here  and  there  about  the  back.  In  one  of  Dr.  Gee's 
cases — a  child  aged  one  year — a  curious  recession  of  the  chest  was  noticed. 
At  each  inspiration  the  whole  of  the  front  sank  inwards,  the  ribs  bending 
on  each  side  at  a  point  much  outside  the  costochondral  articulation,  and 
the  breast-bone  receding  instead  of  protruding  as  in  rickets.  Dyspnoea 
is  not,  however,  mentioned  in  other  recorded  cases  of  the  disease  in  early 
hfe. 

As  the  iUness  j)rogresses  it  is  often  found  that  the  swelling  first  noticed 
begins  after  a  time  somewhat  to  subside,  and  another  lipih  becomes  affected 
in  a  similar  way.  Thus,  in  FUrst's  case  the  earlier  swellings  appeared 
in  the  left  femur  and  the  tibiae  of  both  limbs.  Next,  enlargement  was 
noticed  in  the  right  forearm,  and  afterwards  in  the  left  forearm  and  the 
right  arm.  At  the  time  when  these  secondary  swelhngs  appeared  the  parts 
first  affected  began  to  recover,  and  the  fever  abated.  Even  after  apparently 
complete  recovery  the  disease  is  still  liable  to  recur,  under  the  influence, 
,  probably,  of  the  same  causes  which  provoked  the  original  attack.  Thus,  in 
Mr.  Thomas  Smith's  case  the  child  was  said  to  have  suffered  eleven  months 
previously  fi'om  like  symptoms  which  had  lasted  over  a  period  of  two 
months. 

Fever  is  not  always  present  in  cases  of  scurvy  in  the  child.  Sometimes, 
as  has  been  stated,  the  thermometer  marks  an  elevation  of  101°,  102°,  or 
ever  higher,  but  the  disease  may  run  its  course  without  the  occurrence  of 
pyrexia.  Still,  if  the  hsemorrhagic  effusion  is  great  and  the  tension  of  the 
periosteum  cox'respondingly  severe,  a  certain  amount  of  fever  is  usuaUy  to 
be  noticed. 

When  the  patients  recover,  as  they  will  usuaUy  do  if  suitable  treat- 
ment is  adopted  in  time,  the  temperature  falls,  the  tenderness  subsides,  the 
swellings  disappear,  the  ajDpetite  improves,  and  the  strength  and  colour  re- 
turn. A  degree  of  thickening  is  left  at  first  around  the  bone  at  the  site  of 
the  swelling,  but  this  after  a  time  is  no  longer  to  be  detected.  Even  the^ 
separated  epiphyses  will,  under  favourable  conditions,  become  again  con- 
solidated with  the  shaft  of  the  bone. 

Diagnosis. — In  all  cases  where  a  young  child  presents  symptoms  of 
rickets,  and  it  is  discovered  that  his  feeding  and  management  have  been 
such  as  to  favour  the  special  deterioration  of  the  blood  which  gives  rise  to 
scurvy,  the  symptoms  of  that  disease  should  be  looked  for.  These  always 
supervene  upon  a  state  of  ill-health,  and  never  occur,  as  is  the  case  with 
pui-pura,  in  a  child  whose  condition  is  not  in  other  respects  unsatisfactory. 
Exaggerated  tenderness,  even  in  a  case  of  rickets,  is  a  suspicious  symptom. 
In  rickets  tenderness  is  confined  to  cases  where  the  bone-changes  and 
general  features  of  the  disease  are  pronounced.  If  the  symptom  is  noticed 
in  a  child  who,  although  showing  signs  of  rickets,  is  evidently  sviffering 
from  the  disease  only  in  a  mild  form,  it  points  very  decidedly  to  scurvy. 

When  the  swelhngs  occur  in  the  limbs  the  great  enlargement  without 
17 


258  DISEASE  IN   CHILDEEN. 

fluctuation,  or  redness,  or  local  heat  of  skin,  is  -unlike  ordinary  periostitis, 
and,  indeed,  this  disease  is  not  a  recognized  complication  of  rickets.  If, 
then,  the  patient  be  suffering  from  rickets,  the  probability  of  the  additional 
phenomena  being  due  to  the  supervention  of  scurvy  shotdd  be  considered. 

In  many  cases,  especially  if  separation  of  the  epiphyseal  ends  of  the 
bone  has  occurred,  with  the  symptoms  of  pseudo-paralysis,  the  difficulty  is 
to  exclude  syiDhilis  ;  and  if,  as  may  happen,  there  is  a  history  of  miscar- 
riages on  the  part  of  the  mother,  or  of  doubtful  symptoms  in  the  child 
himself  shortly  after  birth,  it  may  be  impossible  to  exclude  a  syphilitic 
taint.  Still,  the  diagnosis  of  scurvy  may  often  be  ventured  upon.  Sj'philitic 
pseudo-paralysis  is  usually  accompanied  by  enlargement  of  the  spleen  and 
all  the  signs  of  a  profound  syphilitic  cachexia.  The  child  is  greatly  wasted. 
He  is  hoarse  and  snuffles,  the  cranial  bones  have  the  characteristic  thicken- 
ing, and  the  skin  has  the  peculiar  dry,  parchment-like  appearance  so  com- 
mon in  the  inherited  disease.  In  scurvy  the  patients  are  not  as  a  rule 
greatly  emaciated.  Often  their  general  nutrition  is  fair  ;  and  the  special 
cliaracteristics  of  syphilis  are  absent.  If  the  gums  are  spongy  or  signs 
of  haemorrhage  can  be  noticed  in  the  skin  or  elsewhere,  the  evidence  is 
strongly  in  favour  of  scurv5\ 

Prognosis. — If  the  child  be  seen  in  time  and  measures  are  at  once  taken 
to  improve  the  quahty  of  his  food  and  supply  the  lacking  constituents  to 
his  blood,  recovery  may  usually  be  counted  upon.  When  children  die 
in  this  disease  they  die  from  exhaustion.  Much  will  therefore  depend 
upon  those  who  are  entrusted  vdth  the  care  of  the  child,  for  scurvy  is  one 
of  the  maladies  of  which  the  treatment  consists  almost  entirely  in  vigilant 
and  judicious  nursing. 

Ti^eatment. — In  all  cases  of  infantile  scurvy  it  will  be  found  that  the 
child  has  been  deprived  of  fi-esh  milk  and  fed  upon  Swiss  milk  and  other 
kinds  of  tinned  food,  which  are  deficient  in  the  material  necessary  for 
maintaining  all  the  constituents  of  the  blood  at  a  normal  standard.  An 
immediate  change  must  therefore  be  made  in  his  diet.  He  should  be 
given  fresh  cow's  milk,  diluted,  if  necessary,  with  barley-water  or  thickened 
with  a  proportion  of  potato-gruel.  If  he  be  twelve  months  old  raw  mutton 
pounded  in  a  mortar  and  straiued  through  a  fine  sieve,  may  be  given  every 
other  day  alternating  with  raw  meat-juice,'  or  if  the  meat  be  not  well 
digested,  meat-juice  can  be  given  every  day.  If  the  child  refuse  this  food 
the  juice  may  be  sweetened  with  sugar,  or  what  is  much  better  with  tur- 
nip or  carrot.  Orange-juice  is  well  taken  as  a  rule,  even  by  young  babies, 
and  is  a  valuable  anti-scorbutic.  If  the  patient  be  in  a  very  exhausted 
state,  twenty  or  thu'ty  drops  of  brandy  can  be  given  every  three  or  four 
hours  ;  or  he  may  have  one  or  two  teaspoonfuls  of  burgundy  or  the.  St. 
Eaphael  Tannin  wine,  diluted  with  an  equal  prox^ortion  of  water.  At  the 
same  time  care  should  be  taken  to  furnish  a  proper  supply  of  fresh  air.  If 
the  weather  be  suitable  the  child  may  be  taken  out  frequently  lying  at  full 
length  in  a  little  carriage.  If  he  be  confined  to  the  house,  open  windows 
should  be  insisted  upon,  every  precaution  being  taken  to  keep  the  cot  out 
of  the  line  of  direct  draught.  The  best  medicine  is  cod-liver  oil.  This 
may  be  given  with  a  few  drops  of  the  tincture  of  perchloride  of  iron,  or  in 
a  draught  composed  of  three  of  fom-  grains  of  the  citrate  of  iron  and  qui- 
nine dissolved  in  a  teaspoonful  of  lemon-juice,  and  sweetened  with  spirits  of 

1  To  make  raw  meat  jiiice  :  Put  two  ounces  of  lean  raw  mutton  very  finely  minced 
into  an  earthen  vessel,  and  pour  upon  the  meat  enough  cold  water  to  cover  it.  Stand 
inside  the  fender  hefore  the  fire  for  two  hours,  then  strain  through  a  sieve. 


SCUEVY — PROGlSrOSIS — TREATMENT.  259 

chloroform.     An  occasional  powder  of  rhubarb  and  aromatic  chalk  can  be 
given  if  there  is  an  unhealthy  state  of  the  bowels. 

When  the  gums  are  spongy  and  bleeding,  they  may  be  painted  several 
times  a  day  vdth  a  solution  of  glycerine  of  tannin  and  glycerine  of  carbolic 
acid,  fifteen  minims  of  each  to  the  ounce.  This  application  was  used  by 
Dr.  Cheadle  in  his  cases  with  the  best  results.  For  the  swellings  of  the 
limbs  Dr.  Barlow  recommends  surrounding  them  with  wet  compresses 
thoroughly  wrung  out,  and  covered  with  dry  cloths  closely  applied.  An 
operation  seems  to  be  unnecessary,  although  Mr.  Herbert  Page  has  re- 
ported a  case  in  which  he  made  an  incision  through  the  periosteum  and 
turned  out  the  extravasated  clots  without  ill  consequences.  Still,  it  seems 
probable,  from  the  results  in  other  cases,  that  eventual  absorption  of  the 
blood  will  take  place  if  the  child  be  put  under  favourable  conditions  for 
recovery.  If  separation  of  the  epiphyses  has  occurred,  the  limb  must  be 
kept  perfectly  quiet  in  splints. 


Part  5, 
DISEASES  OF  THE  NERVOUS  SYSTEM. 


CHAPTEE  I. 

GENERAL   CONSIDERATIONS. 


The  diseases  of  the  Nervous  System  in  childliood  present  many  difficulties. 
In  early  life  the  excitabihty  of  the  reflex  centres  is  normally  in  excess  ;  and 
can  even  be  heightened  by  causes  which  rapidly  modify  the  general  nutri- 
tion of  the  body.  Consequently  slight  m-itants  may  give  rise  to  symptoms 
of  tumult  in  the  nei'vous  system  which  are  out  of  all  projDortion  to  the  ap- 
parently trifling  character  of  the  lesion  which  has  produced  them.  On 
account  of  this  excessive  irritability  of  the  nervous  system  many  patho- 
logical states  in  the  child  express  themselves  by  convulsive  movements 
which  in  the  adult  are  accompanied  by  much  less  striking  symptoms.  In 
the  young  subject  signs  of  nervous  disturbance  may  arise  quite  indepen- 
dently of  actual  disease  in  the  nei-vous  centres ;  and  the  apparent  violence 
of  the  commotion  is  not  influenced  by  the  seat  of  the  ii'ritant,  and  bears 
no  proportion  to  the  severity  of  the  lesion  of  which  it  is  the  expression. 
Indeed,  the  same  violent  spasmodic  movements  may  be  the  consequence 
of  lesions  so  various  in  situation  and  in  gravity,  that  in  a  case  where  such 
symptoms  are  noticed  it  is  often  by  no  means  easy  to  discover  the  position 
of  the  irritant  or  to  say  at  first  whether  or  not  the  nervous  centres  axe  free 
from  disease. 

.  In  children  investigation  of  disease  of  the  cerebro-spinal  system  is  car- 
ried on  by  means  exactly  the  same  as  are  employed  in  the  case  of  the  adult. 
As,  however,  the  young  child  cannot  describe  his  sensations  we  have  to 
trust  much  to  objective  symptoms,  and  are  dependent  upon  the  memory 
and  observation  of  others  for  important  information  as  to  pecuHai'ities  of 
manner  and  changes  in  temper  and  disposition. 

Of  the  symptoms  to  which  cerebral  disease  gives  rise  some  are  peculiar 
to  a  centric  lesion,  while  others  are  present  in  every  case  of  nervous  dis- 
turbance, however  it  may  have  originated.  In  eveiy  variety  of  acute  ill- 
ness in  the  young  child  the  impressionable  nervous  system  shows  signs  of 
distress.  This  is  well  seen  in  a  case  of  acute  indigestion.  .  The  skin  be- 
comes burning  hot  ;  the  child  is  restless,  cries  and  talks  wildly  ;  he 
twitches  and  starts  in  his  uneasy  sleep  and,  if  an  infant,  may  be  violently 


DISEASES   OF   THE  NERVOUS   SYSTEM — SYMPTOMS.  261 

convulsed.  These  symptoms  indicate  nervous  disturbance  but  are  not  dis- 
tinctive of  cerebral  lesion.  So,  again,  a  child  may  scream  out  with  pain, 
and  frequently  carry  his  hand  to  his  forehead  or  ear,  without  his  headache 
being  necessarily  a  sign  of  disease  of  the  brain. 

There  are  other  symptoms  which  are  more  directly  indicative  of 
cerebral  origin  ;  but  which  may  still  be  present  without  owing  their  rise 
to  any  discoverable  lesion  of  the  nervous  centres.  Thus,  squinting  is  a 
sign  which  should  always  be  viewed  with  great  suspicion.  It  is  frequently 
present  in  convulsions,  whatever  their  cause,  and  may  even  continue  after 
the  nervous  seizure  is  at  an  end  without  being  necessarily  a  sign  of  any- 
thing more  serious  than  derangement  of  function.  Sometimes  the  defect 
becomes  a  permanent  one,  and  yet  after  death  from  some  accidental  cause 
a  post-mortem  examination  of  the  body  discovers  no  lesion  within  the  skull. 
Strabismus  is  not  therefore  necessarily  a  grave  symptom.  Still,  it  is  so 
frequently  a  consequence  of  serious  disease  of  the  brain  and  membranes 
that  its  persistence  after  a  convulsive  attack  should  always  give  rise  to  un- 
easiness. An  external  squint,  when  it  occurs  without  having  been  pre- 
ceded by  spasmodic  movements,  is  often  a  sign  of  pressure  upon  the  cor- 
responding crus  cerebri,  and  may  be  an  early  symptom  of  cerebral  tumour. 
Strabismus  may,  however,  occur  as  a  consequence  of  hypermetropia ;  and 
an  intermittent  squint  is  not  uufrequently  a  symptom  of  chronic  digestive 
derangement.  Therefore,  in  all  cases,  careful  search  should  be  made  for 
further  evidence.  In  the  case  of  cerebral  tumour  external  squint  is  usually 
associated  with  ptosis  and  dilated  pupils ;  headache  and  vomiting  will 
probably  have  been  complained  of ;  there  may  be  tremors  or  spasmodic 
movements  in  other  muscles  ;  the  sight  is  often  impaired,  and  an  ophthal- 
moscopic examination  may  reveal  the  presence  of  optic  neuritis. 

Nystagmus,  or  small  consensual  oscillations  of  the  eyeballs,  very  often 
indicates  the  presence  of  cerebral  disease.  It  is  common  in  the  second 
and  third  stages  of  tubercular  meningitis,  and  is  then  accompanied  by 
severe  and  obvious  symptoms  of  intra-cranial  mischief.  It  is  not  uu- 
frequently seen  in  chronic  hydrocephalus  and  even  in  simple  oedema  of 
the  brain,  and  is  sometimes  present  as  a  consequence  of  cerebral  atrophy. 
In  cases  of  tumour  of  the  brain  nystagmus  often  precedes  paralysis  of  the 
ocular  muscles  as  an  early  symptom  of  a  growth  within  the  skull.  Nys- 
tagmus is  not,  however,  always  a  consequence  of  cerebral  mischief.  If  it 
occurs  in  an  infant  in  whom  no  other  sign  of  nervous  disturbance  has 
been  noticed  it  should  suggest  a  congenital  cataract  ;  for  this  lesion  if  left 
untreated  is  apt  to  induce  oscillatory  movements  of  the  eyeball  from  alter- 
nate contractions  of  the  recti  and  oblique  muscles  of  the  eye.  Even  in 
older  children  the  symptom  may  be  due  to  a  congenital  cataract  which  has 
been  overlooked.  In  rare  cases  nystagmus  is  the  consequence  of  a  local 
chorea. 

The  condition  of  the  pupils  should  be  always  noted.  During  sleep  in 
a  healthy  child  the  pupils  are  contracted  but  they  dilate  when  the  child 
wakes  up.  They  are  contracted  in  the  early  stage  of  meningitis,  either 
the  simple  or  tubercular  form,  and  are  also  smaU  if  opium  has  been  ad- 
ministered in  too  large  quantities.  In  the  later  stage  of  meningitis  and  in 
many  forms  of  cerebral  disease  the  pupils  are  large  and  equal.  If  they  are 
sluggish  and  contract  imperfectly  or  not  at  all  under  the  influence  of  light, 
the  sign  is  a  very  grave  one.  If  they  are  unequal  on  the  two  sides,  the 
eyes  themselves  being  perfectly  free  from  disease,  we  can  have  little  hope 
of  the  patient's  recovery. 

Impairment  or  loss  of  sight  is  another   symptom  of   importance.     In 


262  DISEASE   IN   CHILDEEN. 

tumour  of  the  brain  it  occurs  early,  and  if  combined  with  headache  and 
vomiting  is  very  characteristic  of  a  cerebral  growth.  It  is  often  observed 
in  meningitis  and  in  thrombosis  of  the  cerebral  sinuses.  In  these  cases 
optic  neuritis  may  perhaps  be  discovered  by  the  ophthalmoscope. 

Delirium  in  the  young  baby  is  indicated  by  sudden  screams,  staring  of 
the  eyes,  and  a  frightened  look.  In  the  older  child  by  restlessness  and 
random  talking,  as  it  is  in  the  adult.  The  symptom  is  comparatively 
rarely  the  consequence  of  cerebral  disease,  although  it  may  occur  in  cases 
of  tubercular  meningitis.  As  a  rule,  dehrium  in  the  child  is  evidence 
either  of  digestive  derangement,  of  the  febrile  state,  or  of  some  altered 
condition  of  the  blood  such  as  obtains  in  the  acute  specific  fevers.  In  ex- 
ceptional cases  a  transient  deliiium  may  be  due  to  mere  weakness,  and 
may  be  seen  on  the  subsidence  of  pyrexia  at  the  end  of  an  attack  of  acute 
febrile  disease.  In  such  a  case  it  disappears  at  once  when  the  child  is 
sjDoken  to  and  he  answers  perfectly  rationally.  Early  and  pronounced 
delirium,  accompanied  by  a  high  temperature,  is  very  commonly  induced 
by  croupous  pneumonia  ;  and  in  any  illness  beginning  with  such  symp- 
toms it  is  to  this  disease  that  our  thoughts  would  naturally  turn. 

Droicsiness,  with  dilated  pupils,  passing  into  stupor,  is  often  a  sign  of 
intra-cranial  mischief.  After  a  fit  of  convulsions  fi'om  reflex  iiTitation,  the 
child  may  be  drowsy  for  an  hoiu'  or  two  ;  but  unless  congestion  of  the 
brain  have  suj)ervened  and  effusion  of  fluid  have  taken  place  into  the  skull 
cavity,  it  is  a  symptom  which  in  such  a  case  soon  passes  away.  If  the  fits 
are  frequently  repeated,  and  in  the  intei'vals  the  child  is  hea^y  and  stupid, 
with  large  sluggish  pupils ;  if  he  takes  no  notice  of  familiar  faces ;  and 
esjDecially  if  the  temperatiu'e  is  high,  and  there  are  signs  of  headache,  the 
case  is  probably  one  of  meningitis. 

It  must,  however,  be  borne  in  mind  that  drowsiness  approaching  even 
to  stupor  may  be  present  without  being  due  to  a  cerebral  lesion.  Certain 
cases  of  pneumonia  in  the  child  are  accompanied  by  stupor  without  the 
temperatui'e  being  extraordinaidly  elevated,  and  may  give  rise  to  strong 
suspicions  of  cerebral  disease.  In  such  cases  there  is  often  httle  to  attract 
attention  to  the  chest,  and  all  the  symptoms  point  to  the  brain  as  the  pai-t 
affected.  So,  also,  at  the  beginning  of  certain  fevers,  in  ursemia,  and  even 
in  some  cases  of  severe  gastric  disturbance  there  may  be  great  di'owsiness 
and  stupor,  although  there  is  no  lesion  of  the  brain. 

Loss  of  consciousness  is  not  easy  to  detect  in  infants.  The  popular  test 
is  the  capabihty  of  recognising  a  famihar  face.  If  the  baby  no  longer 
"takes  notice,"  he  is  thought  to  be  unconscious.  But  it  must  be  remem- 
bered that  impairment  of  sight  is  an  early  symptom  of  tumour  of  the 
brain,  and  may  be  present  in  other  forms  of  cerebral  disease.  A  child, 
therefore,  may  cease  to  recognise  objects  and  faces  because  his  sight  and 
not  his  intelhgence  is  defective.  In  all  cases  of  unconsciousness  or  sup- 
posed imconsciousness  it  is  important  to  notice  if  the  child  still  takes  hquid 
food.  An  infant,  if  his  stupor  is  profound,  or  if  he  is  suffering  pain  in 
the  head  or  elsewhere,  refuses  his  food ;  while,  if  he  is  only  stupid  and 
drowsy,  without  being  completely  comatose,  and  is  in  no  pain,  he  will 
often  take  his  bottle  "with  aridity.  In  cerebral  haemorrhage  and  serous 
effusion  a  child  sucks  well  from  the  bottle.  "WTien  he  is  tortured  with  ear- 
ache or  abdominal  coUc,  he  refuses  all  food  while  the  pain  lasts  ;  and  a 
child  suffering  fi'om  meningitis  can  only  be  fed  with  gi'eat  difficulty. 

Changes  of  temper  should  be  always  inquired  for.  At  the  beginning  of 
many  cerebral  diseases  the  child  often  seems  unaccountably  wayward  and 
capricious.     He  is  fretful  without  cause,  or  spiteful,  or  sullen  and  morose. 


DISEASES   OF  THE  NERVOUS   SYSTEM — SYMPTOMS.  263 

These  symptoms  are  not,  however,  confined  to  cases  of  brain  affection. 
The  same  change  is  often  noticed  in  chronic  abdominal  derangements,  and 
may  be  a  symptom  of  epilepsy. 

Tremors,  spasms,  and  paralysis  are  symptoms  which  derive  their  value 
from  the  connection  in  which  they  are  found. 

Tremors  are  sometimes  a  result  of  mere  weakness,  as  when  they  occur 
in  the  late  period  of  typhoid  fever.  In  such  a  case  they  are  general,  and 
the  condition  of  the  patient  is  one  of  extreme  debihty.  When  they  result 
from  cerebral  disease  they  are  often  confined  to  one  Hmb  or  to  a  group  of 
muscles.  In  such  a  case,  if  they  are  repeated,  and  occur  always  in  the 
same  part,  they  should  excite  suspicions  of  tubercle  of  the  brain.  If 
rhythmical,  they  would  suggest  disseminated  sclerosis,  although  this  is  a 
rare  disease  in  childhood. 

Spasms  or  convulsive  movements,  both  clonic  (intermittent  contractions) 
and  tonic  (persistent  contractions)  may  be  general  or  limited,  like  the 
tremors  to  one  side  of  the  body,  to  a  group  of  muscles,  or  even  to  a  single 
muscle.  As  a  result  of  cerebral  disease  they  are  often  so  limited.  Thus, 
if  a  child  be  subject  to  epileptiform  convulsions  which  affect  exclusively 
one-half  of  the  body,  some  lesion  (often  a  mass  of  cheesy  matter)  may  be 
suspected  in  the  opposite  hemisphere  of  the  brain.  Still,  a  general  con- 
vulsion, as  has  already  been  remarked  at  the  beginning  of  this  chapter,  is 
not  necessarily  a  sign  of  disease  of  the  brain  ;  for  in  certain  subjects  a 
very  trifling  and  passing  irritant  is  able  to  induce  it.  This  subject  is 
treated  of  at  length  in  a  separate  chapter  (see  Convulsions). 

Paralysis  is  commonly  a  consequence  of  disease  of  the  brain  or  spinal 
cord  ;  but  even  this  symptom  may  be  sometimes  referred  to  a  less  serious 
origin.  Thus  a  temporary  loss  of  power  may  follow  a  severe  and  pro- 
longed attack  of  convulsions,  and  is  then  attributed  to  exhaustion  of  nerve- 
force  as  a  consequence  of  the  seizure.  This  form  of  paralysis  soon  passes 
off.  If  it  persist  for  a  week  or  longer,  it  is  probable  that  a  lesion  of  the 
brain  has  actually  occurred.  Again,  facial  paralysis  may  be  the  result  of 
causes  acting  upon  the  facial  nerve  after  its  point  of  exit  fi'om  the  tem- 
poral bone.  An  infant  may  be  born  paralysed  on  one  side  of  his  face 
from  pressure  of  the  forceps  upon  the  trunk  of  the  nerve  ;  and  in  older 
children  rheumatic  inflammation  of  the  nerve-sheath  from  a  chill  may  be 
followed  by  the  same  deformity. 

Even  paralysis  due  to  cerebral  or  spinal  disease  is  not  always  perma- 
nent. When  the  patient  survives,  power  in  the  affected  limbs  is  often 
recovered  more  or  less  completely.  Thus,  paralysis  due  to  myelitis  affect- 
ing the  anterior  cornua  of  the  spinal  cord  (infantile  spinal  paralysis),  at 
first  very  extensive,  may  be  found  in  a  few  days  or  weeks  to  have  limited 
itself  to  one  limb,  or  even  to  a  single  muscle.  Again,  a  j^aralysis  from 
cerebral  haemorrhage  is  often  recovered  from  if  the  child  survive  ;  and  the 
mysterious  form  of  paralysis  which  sometimes  follows  an  attack  of  diph- 
theria generally  passes  off  completely  after  a  time.  The  loss  of  power  is 
often  very  partial,  and  affects  special  muscles.  In  cases  of  cerebral  tumour 
it  may  be  limited  to  the  muscles  of  the  eye  or  face. 

The  various  forms  of  paralysis  in  children  which  result  from  clot,  em- 
bolism, or  other  shock  to  the  brain,  are  usually  accompanied  by  aphasia. 
With  regard  to  this  symptom  it  may  be  noted  that  loss  of  speech  is  of  less 
value  in  early  life,  as  indicating  the  seat  of  the  lesion,  than  it  is  held  to  be 
in  the  adult.  Indeed,  in  the  young  subject  aphasia  may  be  present  although 
the  brain  itself  is  free  from  disease.  It  must  be  remembered  that  in  a  child 
of  five  or  six  years  old  the  power  of  talking  is  a  comparatively  recent  ac- 


264  DISEASE  IN   CHILDREN. 

complisliment,  and  that  the  utterance  of  any  but  the  most  simple  phrase 
requires  a  distinct  intellectual  effort.  In  many  weakened  states  of  the 
body — whether  produced  by  general  disease  or  special  injury  to  the  cere- 
brum— the  necessary  effort  cannot  be  made.  Consequently,  any  shock  to 
the  system  will  in  many  children  take  away  for  a  considerable  time  the 
faculty  of  articulate  sjDeech. 

Rigidity  may  be  noticed  in  the  affected  parts.  If  the  paralysis  be  per- 
manent, rigidity  and  contraction  may  eventually  ensue.  Eigidity,  how- 
ever, is  often  a  merely  temporary  j)henomenon  which  affects  various  joints 
and  comes  and  goes  irregularly.  This  is  often  seen  in  cases  of  tubercular 
meningitis.  Other  forms  of  rigidity  of  the  joints  are  seen  in  children.  Tonic 
contractions  may  occur  in  the  extremities  fi-om  reflex  disturbance  of  the 
nervous  system  (see  page  274) ;  the  limbs  may  be  the  seat  of  spastic  rigid- 
ity from  disease  of  the  spinal  cord  ;  and  in  girls  of  ten  or  twelve  years 
old  the  so-called  hysterical  contractions  of  the  joints  are  by  no  means 
rare. 

A  common  form  of  rigidity  is  that  which  affects  the  muscles  of  the 
nucha  and  causes  retraction  of  the  head  upon  the  shoulders.  This  symjD- 
tom  is  a  common  one  in  cases  of  cerebral  disease,  and  is  a  certain  sign  of 
intra-cranial  lesion.  Mere  stiffness  of  the  neck  is  not  here  referred  to. 
This  may  be  due  to  many  causes,  such  as  cervical  caries,  rheumatism,  etc. 
In  the  retraction  of  the  head  so  often  induced  by  brain  affection  the  head 
is  drawn  backwards  upon  the  shoulders  by  rigidly  contracted  muscles  at 
the  back  of  the  neck.  This  condition  may  be  associated  with  rigidity  of 
limbs,  epileptiform  fits,  and  hydrocephalus.  It  is  often  due  to  basic  men- 
ingitis, and  may  be  the  consequencee  of  mere  distention  of  the  lateral 
ventricles  with  fluid.  It  is  a  grave  symptom,  although  not  necessarily  a 
fatal  one.     Sometimes  it  is  intermittent.' 

Besides  the  symptoms  connected  especially  with  the  brain,  others  de- 
rived from  disturbance  of  distant  organs  may  ftu-nish  signs  not  to  be  neg- 
lected of  a  cerebral  origiu.  So  gTeat  is  the  sympathy  between  the  various 
organs  of  the  body  in  earty  life  that  disease  in  the  central  nervous  system 
is  invariably  associated  with  more  or  less  general  disorder  of  function. 

Vomiting  is  rarely  absent  in  cases  of  cerebral  disease.  It  happens  not 
only  after  meals,  but  at  other  times ;  and  when  retching  occurs  on  an 
empty  stomach,  or  is  excited  by  merely  raising  the  child  up  from  his  bed, 
it  is  a  very  characteristic  symptom.  Constipation,  also,  if  obstinate,  is  a 
sign  not  without  importance  ;  and  if  associated  with  vomiting,  and  occur- 
ring in  a  child  in  whom  gradual  failure  of  health  has  been  noticed,  is  very 
suspicious  of  tubercular  meningitis.  Even  the  amount  of  tension  of  the 
abdominal  wall  is  a  matter  not  to  be  disregarded.  In  tubercular  menin- 
gitis the  softness  and  loss  of  elasticity  of  the  parietes  is  sufficiently  obvious 
to  the  touch,  and  at  the  same  time  the  wall  is  depressed  and  retracted  in  a 
manner  peculiar  to  this  disease. 

The  state  of  the  breathing  must  be  noticed.  In  many  forms  of  brain 
lesion  the  respirations  become  very  irregular,  and  this  alteration  of  rhythm 
may  be  sometimes  a  very  important  sign.  In  tubercular  meningitis,  espe- 
cially, great  irregularity  of  breathing,  with  fi'equent  sighs  and  occasional 
long  pauses  during  which  the  chest-walls  are  not  seen  to  move,  is  a  valuable 

'  It  is  important  not  to  confound  the  involuntary  contraction  of  the  head  from  rigidly 
contracted  rauscles  with  the  voluntary  bending  back  of  the  head  which  is  seen  in  in- 
fants who  are  suffering  from  the  pressure  of  an  abscess  upon  the  larynx.  Such  cases 
are  accompanied  by  lividity  of  the  face  and  urgent  dyspnoea  ;  and  a  swelling  can  often 
be  felt  at  the  back  of  the  pharynx. 


DISEASES   OF   THE  NERVOUS   SYSTEM — SYMPTOMS.  265 

aid  to  diagnosis  when  the  nature  of  the  disease  is  doubtful.  There  is  a 
peculiar  form  of  breathing,  called  from  the  writers  who  have  drawn  atten- 
tion to  it  the  "  Cheyne-Stokes  "  type,  which,  although  not  peculiar  to  cere- 
bral disease,  is  yet  often  noticed  in  such  affections.  It  consists  of  a  series 
of  inspirations  gradually  increasing  in  depth  and  strength,  and  then  as 
gradually  diminishing,  until  the  movement  of  the  chest-wall  is  hardly  per- 
ceptible. There  are  many  theories  as  to  the  pathology  of  this  peculiar 
respiration.  In  most  of  them  a  supposed  diminution  in  the  excitability  of 
the  respiratory  centre  is  a  prominent  feature.  This  type  of  breathing  is 
often  associated  with  headache  and  delirium,  and  may  be  found  in  disor- 
ders of  the  heart  and  kidneys  as  well  as  of  the  brain.  Still,  when  it  is 
found,  whatever  be  the  disease,  some  nervous  complication  is  usually 
present. 

Information  can  also  be  derived  from  the  state  of  the  circulation.  In 
the  earlier  period  of  meningitis  the  pulse  often  falls  in  frequency  and  at  the 
same  time  becomes  intermittent.  If  a  child  with  a  temperature  of  102° 
have  a  pulse  of  70°,  especially  if  its  rhythm  be  irregular,  we  should  suspect 
the  presence  of  tubercular  meningitis.  It  must  not  be  forgotten,  however, 
that  a  slow  pulse  is  not  uncommon  in  children  during  convalescence  from 
acute  disease,  and  that  this  slow  j)ulse  may  be  irregular  or  even  completely 
intermit  at  times,  especially  during  sleep.  We  must  not,  therefore,  attach 
too  great  importance  to  this  symptom  alone,  unless  the  temperature  be 
elevated,  and  the  child's  state  be  one  to  excite  anxiety. 

Again,  a  remarkable  modification  in  the  vascularity  of  the  skin  is  often 
seen  in  cases  of  tubercular  meningitis.  The  child  often  flushes  up  sud- 
denly, and  slight  pressure  upon  the  skin,  especially  that  of  the  face,  the 
abdomen,  and  the  front  of  the  thighs,  produces  a  bright  redness  which  re- 
mains for  many  minutes.  This  cerebral  flush  (called  by  Trousseau,  who 
first  drew  attention  to  it,  tache  cerebrale),  although  perhaps  more  vivid  and 
persistent  in  this  disease,  is  yet  not  peculiar  to  tubercular  meningitis.  It 
may  be  often  produced  by  gentle  pressure  in  sensitive  children,  especially 
if  they  are  the  subjects  of  pyrexia. 

In  all  cases  of  paralysis  in  the  child  a  careful  examination  should  be 
made  of  the  heart.  Children,  hke  their  elders,  are  subject  to  embohsms, 
and  if  sudden  hemiplegia  occur  in  a  child  who  suffers  from  valvular  disease 
of  the  heart,  we  have  reason  to  attribute  the  paralysis  to  this  cause. 

Lastly,  the  state  of  the  urine  must  not  be  forgotten.  Coma  and  con- 
vulsions from  Bright's  disease  are  not  uncommon  in  children.  If,  in  such 
a  case,  oedema,  however  slight,  be  discovered,  and  an  examination  of  the 
water  reveals  the  presence  of  albumen,  we  can  have  little  hesitation  in 
attributing  the  nervous  symptoms  to  a  toxic  cause. 

To  make  a  complete  examination  of  a  young  child  in  whom  we  suspect 
the  existence  of  a  cerebral  lesion,  all  these  points  should  be  taken  into  con- 
sideration. In  addition,  it  is  important  to  study  the  face  and  expression 
of  the  patient,  for  by  this  means  we  may  often  exclude  serious  disease.  A 
teething  child  who  has  just  had  a  fit  seldom  looks  ill — that  is  to  say,  his 
face  has  not  the  weary,  haggard  look  which  severe  acute  disease  imprints 
upon  it  from  the  first.  If  the  child's  face  looks  pinched  and  distressed  we 
may  be  sure,  however  apparently  trifling  the  symptoms  may  be,  that  the 
case  is  a  serious  one. 

In  connection  with  this  subject  of  nervous  symptoms  in  children  it  is 
important  to  remember  that  in  them — even  in  children  three  and  four 
years  old — we  must  be  prepared  occasionally  to  find  the  peculiar  function- 
al disorders   of  the  nervous  system  which  in  the  adult  are  called  hys- 


266  DISEASE   IN   CHILDEEN. 

teria.  These  disorders  are  found  botli  amongst  boys  and  girls,  and  have 
no  necessary  relation  to  puberty  or  the  establishment  of  the  catamenial 
function.  Sensitive  children,  if  frightened  by  the  shock  of  a  fall  or  other 
nervous  impression,  ma}^  be  seized  Avith  convulsions  of  hysterical  tj^pe  and 
have  various  modifications  of  sensibility  of  the  skin,  combined,  perhaps, 
with  impairment  or  disorder  of  motor  power.  Aphonia,  blindness,  deafness, 
anaesthesia,  analgesia,  hypersesthesia,  rigidities,  and  paralyses  may  be  all 
met  with  from  this  cause.  It  is  possible  that  in  some  of  these  cases  the 
child  is  addicted  to  excessive  masturbation,  and  some  instances  have  been 
published  in  which  there  can  be  little  doubt  that  debility  and  exhaustion 
of  nerve-power  induced  by  this  means  were  the  cause  of  the  nervous  dis- 
turbance. Often,  however,  there  is  no  reason  to  suspect  any  such  agency. 
The  patient  is  a  strong,  healthy-looking  child  with  firm  muscles  and  well- 
developed  limbs.  In  not  a  few  such  cases  the  derangement  can  be  referred 
to  a  fright  or  other  shock  to  the  nervous  system. 

Cases  illustrating  these  various  conditions  are  published  from  time  to 
time  in  the  medical  journals,  and  all  busy  practitioners  must  occasionally 
meet  with  them.  They  are  usually  readily  cured  by  the  application  of  a 
moderate  galvanic  current. 

The  diagnosis  is  not  difiicult.  The  derangement  being  purely  func- 
tional, no  nutritive  changes  can  be  detected.  Thus  the  paraplegic  child 
has  full,  firm  hmbs  with  no  sign  of  muscular  wasting.  In  the  child  who 
professes  that  he  cannot  see,  and  gropes  his  way  hke  a  bhnd  person,  the 
retina  shows  no  change  to  the  ophthalmoscope,  the  cornea  is  bright,  and  the 
pupils  contract  normally.  Moreover,  in  almost  all  instances  we  may  suspect 
the  nature  of  the  case,  partly  from  the  character  of  the  symptoms  them- 
selves, partly  from  the  general  appearance  of  the  child,  and  partly  from  the 
absence  of  other  signs  of  serious  organic  disease. 


CHAPTEE  II. 

LARYNGISMUS  STRIDULUS. 

Laeyngismus  steidulus  (child-crowing,  spasm  of  the  glottis,  internal  con- 
vulsion) is  very  common  in  England,  The  complaint  is  a  form  of  convul- 
sive seizure  which  is  limited  to  the  muscles  of  respiration.  Sometimes  it 
affects  exclusively  the  muscles  of  the  glottis  ;  in  other  cases  it  may  impli- 
cate also  the  diaphragm  and  other  muscles  concerned  in  breathing.  The 
disorder  must  not  be  confounded  with  laryngitis  stridulosa,  in  which  there 
is  inflammation  of  the  glottis  with  spasm  superadded.  Laryngismus,  as  it 
affects  the  vocal  cords,  is  a  pure  spasm,  arising,  as  other  spasmodic  attacks 
are  so  apt  to  do  in  the  child,  from  reflex  irritation. 

'Causation. — The  complaint  may  be  met  with  under  two  different  con- 
ditions :  In  new-born  infants  in  whom  no  other  deviation  from  health  can 
be  observed,  and  in  rickety  children  between  the  ages  of  six  or  eight 
months  and  two  years. 

The  spasm  appears  to  be  predisposed  to  by  foul  air  and  hot,  ill-venti- 
lated rooms.  It  is  a  remarkable  and  suggestive  fact  that  the  disorder  is 
essentially  a  winter  complaint,  being  prevalent  when  windows  and  doors 
are  kept  closed  for  the  sake  of  warmth.  It  is  rarely  seen  in  summer,  when 
every  window  is  open  to  admit  the  air.  Still,  the  derangement  may  occur 
without  our  being  able  to  attribute  it  to  any  impurity  in  the  air.  In  these 
cases  it  may  be  due  to  some  special  irritabihty  of  the  reflex  centres  peculiar 
to  the  individual  infant. 

Few  writers  now  hold  the  opinion  that  laryngismus  is  the  result  of  pres- 
sure upon  the  vagus  or  its  branches  by  an  enlarged  thymus  gland.  Were 
this  so,  cases  of  laryngeal  spasm  would  surely  be  much  more  numerous 
than  they  actually  are.  Moreover,  M.  Herard  has  reported  that  in  six 
children  who  had  died  from  this  complaint,  the  size  of  the  gland  presented 
such  striking  variations  that  it  was  impossible  to  connect  it  with  the  pro- 
duction of  the  laryngismus  from  which  they  had  suffered.  It  is  equally 
improbable  that  pressure  of  any  other  kind  set  up  on  the  pneumogastric  or 
its  recurrent  branch  can  produce  the  disorder.  The  effects  of  such  pressure 
in  the  case  of  enlarged  bronchial  glands  are  well  known.  Hoarseness  of  the 
voice  and  violent  paroxysmal  cough  are  early  symptoms,  and  if  spasm  is 
induced  it  occui's,  usually,  at  a  late  period,  when  the  existence  of  the  dis- 
ease is  beyond  a  doubt.  Spasm  occurring  alone  without  warning,  and  as 
suddenly  subsiding  without  other  symptoms  being  noticed,  is  not  a  char- 
acteristic of  enlarged  bronchial  glands. 

The  association  of  laryngismus  with  rickets  is  indisputable.  It  was 
first  pointed  out  by  Elsasser,  and  was  dwelt  upon  by  Sir  William  Jenner 
in  his  lectures  on  rickets  in  1860,  and  more  lately  by  Drs.  Gee  and  Henoch. 
For  many  years  I  have  paid  attention  to  this  matter,  and  can  call  to  mind 
but  few  cases  of  laryngismus  occurring  after  the  age  of  six  months  in  which 
the  child  was  not  rickety  in  some  degree.  It  is  important  to  remember,  in  in- 


268  DISEASE  IjST   CHILDKEN. 

vestigating  this  point,  that  the  patients  do  not  always  show  a  marked  degree 
of  rickets.  They  may  do  so  ;  but  as  often,  perhaps,  as  not,  the  child  is  fat, 
although  pale  and  flabby — a  big  child,  although  a  weak  one.  This  connec- 
tion with  rickets — a  disease  in  which  the  irritability  of  the  nervous  centres 
is  known  to  be  exalted — is  a  strong  argument  in  favour  of  the  reflex  origin 
of  the  spasm.  It  also  serves  to  explain  the  cases  where  many  children  of  a 
family  have  suffered  in  turn  from  the  complaint ;  for  when  a  first  child  is 
rickety  the  others  who  are  brought  up  under  similar  conditions  usually  be- 
come so  too.  Moreover,  the  tendency  to  laryngismus  is  often  combined 
with  a  tendency  to  tonic  and  clonic  spasm.  In.  the  same  family  one  child 
may  suffer  from  spasm  of  the  glottis,  another  from  general  convulsions  ; 
or  in  the  same  child  attacks  of  laryngismus  may  alternate  with  general 
eclamptic  seizures,  or  may  even  be  complicated  by  them.  That  the  latter 
disturbance  is  often  a  pare  neurosis  is  universally  conceded  ;  it  seems, 
therefore,  needlessly  creating  a  difficulty  to  search  for  a  different  explana- 
tion for  the  former.  Still,  many  other  conditions  have  been  said  to  be 
capable  of  causing  the  complaint.  Various  lesions  of  structure  connected 
with  the  cerebro-spinal  system  have  been  discovered  in  children  dying  in 
a  spasm,  and  in  all  of  these  cases  a  connection  has  been  supposed  to  exist 
between  the  symptoms  observed  during  life  and  the  morbid  appearances 
found  in  the  dissecting-room.  Thus  the  laryngeal  trouble  has  been  referred 
to  chronic  hydrocephalus,  to  exostosis  in  the  skull  cavity,  or  to  actual 
pressure  of  the  pillow  upon  a  softened  occiput.  It  seems  highly  probable 
that  in  aU  these  cases  the  special  pathological  condition  has  been  a  pure 
coincidence,  or  at  any  rate  has  had  only  an  indu-ect  influence  in  inducing 
the  nervous  commotion.  That  no  evident  tissue  change  is  needed  to  excite 
a  perfect  and  even  fatal  spasm  is  proved  by  the  numerous  cases  on  record 
in  which,  after  death  in  laryngismus  from  apnoea,  no  lesion  of  the  cerebro- 
spinal system  or  of  the  glottis  could  be  detected.  It  is  equally  certain  that 
under  ordinary  cii-cumstances  intracranial  inflammations  and  effusions  do 
not  produce  spasm  of  the  glottis,  and  there  is  no  e^ddence  that  pres- 
sure upon  the  substance  of  the  brain  or  spinal  cord  will  have  any  such 
effect. 

The  exciting  cause  of  the  seizure  is  usually  some  peripheral  irritant,  as 
in  the  case  of  reflex  convulsions.  There  may  be  disorder  of  the  digestion 
or  other  irritation  of  the  stomach  or  bowels,  or  a  swollen,  tense  gum.  The 
child  may  have  been  exposed  to  a  sudden  chill,  and  according  to  Henoch 
cold  and  catarrh  of  the  air-passages  are  the  most  frequent  source  of  this 
form  of  reflex  irritation.  Li  the  few  cases  which  have  come  under  m.j  notice 
of  laryngismus  attacking  a  child  some  time  after  bii'th  -^here  symptoms 
of  rickets  were  completely  absent,  the  spasms  appeared  to  be  due  to  shght 
larj-ngeal  catarrh  occurring  in  a  nervous,  sensitive  child.  I  was  asked  some 
time  ago  to  see  a  healthy  baby,  seven  months  old,  who  had  cut  two  teeth 
and  was  cutting  his  upper  incisors.  The  little  boy  was  peculiarly  preco- 
cious, and  had  the  bright,  intelligent  face  of  one  twice  his  age.  There  was 
no  enlargement  of  the  ends  of  the  bones  or  other  sign  of  rickets.  The 
child  was  brought  up  at  the  breast,  and  his  general  health  was  good  al- 
though his  bowels  were  habitually  costive.  Some  days  before  my  ^dsit  the 
child  had  caught  cold  and  had  begun  to  cough.  His  voice  also  had  been 
husky.  Since  that  time  he  had  alarmed  his  parents  by  occasionally  mak- 
ing a  noise  in  his  throat  "like  the  crowing  of  a  cock."  He  did  not  suffer 
from  dyspnoea,  nor  was  there  any  lividity  of  the  face.  The  sound  was 
evidently  due  to  a  slight  spasm  of  the  larynx,  which  passed  off  almost  im- 
mediately and  seemed  to  cause  little  inconvenience  to  the  infant  himself. 


LARYNGISMUS   STEIDULUS— CAUSATION — SYMPTOMS.         269 

The  child's  bowels  were  attended  to  and  he  was  given  half  a  grain  of 
chloral  twice  a  day.     The  symptom  then  soon  subsided. 

In  cases  where  there  is  great  irritability  of  the  nervous  system  cough 
or  even  swallowing  may  induce  a  paroxysm.  Anything  which  frightens  or 
iiTitates  the  patient  may  produce  the  same  result.  Thus  in  a  young  child 
who  is  subject  to  the  attacks  a  fit  of  crying  may  bring  on  a  seizure. 
Sometimes,  again,  the  complaint  is  a  relic  of  pertussis,  the  spasm  remaining 
although  the  other  symptoms  of  the  disease  have  passed  away. 

Symptoms. — We  may  often  notice  in  rickety  babies  an  occasional  crow 
or  croak  in  their  breathing  which  seems  to  cause  them  Uttle  or  no  incon- 
venience. In  some  children  this  symjotom  may  continue  for  weeks  and 
then  disappear  without  being  followed  by  anything  more  serious.  In 
others,  after  it  has  continued  for  some  time  the  child  is  suddenly  seized 
with  a  decided  attack  of  laryngismus  stridulus. 

In  a  pronounced  form  of  the  seizure  the  child  ,  becomes  all  at  once 
quite  stiff  and  hes  with  his  head  back,  his  face  congested  and  livid,  his 
eyes  staring,  and  his  expression  haggard  and  frightened.  After  a  few 
seconds  the  spasm  relaxes,  the  breath  is  drawn .  in  with  a  crowing  or 
hissing  sound,  and  the  attack  is  at  an  end.  The  child  then  looks  pale  and 
seems  languid  ;  often  he  goes  to  sleep. 

In  the  more  severe  cases  the  spasm  is  repeated  several  times  at  short 
intervals.  StiU,  actual  closure  of  the  glottis  is  seldom  prolonged  beyond 
a  few  seconds.  There  is  no  pyrexia.  At  the  end  of  an  attack  the  child 
often  vomits,  and  sometimes  he  has  a  good  fit  of  crjdng. 

The  above  is  the  simplest  form  of  the  complaint — that  in  which  the 
spasm  is  limited  to  the  muscles  of  the  glottis.  Even  in  these  cases,  how- 
ever, signs  of  tonic  spasms  in  voluntary  muscles  are  often  to  be  detected. 
The  fingers  are  forcibly  clenched  upon  the  thumbs,  and  the  toes  are  flexed 
under  the  feet.  This  tendency  to  carpo-pedal  spasms  may  continue 
between  the  attacks  and  even  for  some  little  time  after  the  seizures  have 
ceased  to  appear.  The  number  of  the  spasms  and  the  frequency  with 
which  they  are  repeated  vary  considerably  in  different  cases.  Generally 
the  attacks  are  not  very  frequent  at  first,  and  sometimes  after  occurring 
several  times  they  cease  to  appear.  But  if  the  child  be  the  subject  of 
marked  rickets  he  seldom  escapes  so  easily.  The  seizures,  having  once 
begun,  sooner  or  later  return.  In  the  beginning  they  may  be  seen  at 
comparatively  rare  intervals,  and  perhaps  only  after  waking  from  sleep, 
or  when  the  child  is  irritated  or  frightened  ;  but  in  bad  cases  they  may 
recur  so  frequently  that  the  patient  is  in  constant  peril.  Dr.  Roberton 
has  referred  to  a  case  in  which  the  spasms  were  not  absent  for  more  than 
ten  minutes,  day  or  night,  for  ten  months.  Sometimes  they  cease  com- 
pletely for  a  time;  but  return  at  the  end  of  some  weeks,  or  even  months, 
when  a  sufficiently  powerful  exciting  cause  is  again  in  operation. 

As  an  illustration  of  the  length  of  time  during  which  these  attacks 
often  continue,  I  may  instance  a  little  rickety  boy,  aged  twenty  months, 
who  was  an  in-patient  under  my  care  in  the  East  London  Children's  Hos- 
pital. Nine  months  before  the  child  had  had  an  attack  of  whooping-cough. 
After  the  cough  had  subsided  the  laryngeal  spasms  still  continued,  and 
were  often  repeated  eight  or  nine  times  in  the  twenty-four  hours.  He 
had  been  treated  as  an  out-patient  three  months  before  admission  with 
much  benefit,  for  the  paroxysms  had  been  greatly  reduced  in  number, 
although  they  returned  on  the  slightest  provocation.  If  by  any  chance  he 
coughed  he  always  had  an  attack  immediately.  During  the  first  few  days 
after  admission  the  child  had  three  paroxysms  daily.     In  these  attacks, 


270  DISEASE   IN   CHILDEElSr. 

which,  came  on  quite  suddenly,  his  hps  turned  blue,  his  breathing  was 
excessively  difficult,  his  inspirations  were  croupy,  and  his  whole  body 
was  agitated,  although  there  was  no  general  convulsion.  Then  the  spasm 
abruptly  relaxed  and  he  heaved  a  deep  sigh.  After  the  seizure  he  was 
always  very  pale,  but  the  breathing  was  natural  and  there  was  no  hoarse- 
ness. The  child  had  all  the  signs  of  well-marked  rickets.  He  had  only 
six  teeth ;  the  joints  were  large ;  the  fontanelle  was  open ;  the  ribs  were 
very  soft  and  the  lower  part  of  the  thoracic  wall  receded  deeply  at  each 
breath.  The  spleen  was  enlarged,  reaching  nearly  to  the  level  of  the  navel. 
There  were  no  signs  of  swelling  of  the  bronchial  glands.  The  child's 
bowels  were  loose  and  his  motions  very  offensive.  There  was  no  fever. 
In  this  patient  the  spasmodic  attacks  were  cured  almost  immediately  by 
bathing  him  three  times  a  day  in  cold  water. 

A  more  complicated  form  of  the  complaint  is  that  in  which  the  spasm 
is  not  limited  to  the  glottis,  l3ut  involves  also  the  diaphragm  and  other 
respiratory  muscles.  These  cases  assume  much  more  the  characters  of 
general  convulsions,  for  there  is  often  more  or  less  tonic  spasm  of  the 
limbs,  and  consciousness  may  even  be  interfered  with.  Thus  the  child 
Hes  backwards  with  dusky  face,  half-opened  eyelids,  and  upturned  eyes ; 
breathing  is  laboured  andinsj)iration  difficult  and  crowing  ;  the  diaphragm 
acts  irregularly  ;  and  there  are  often  convulsive  contractions  of  the  mus- 
cles, causing  profound  recession  of  the  lower  ribs  and  soft  parts  of  the 
chest.  Sometimes  for  a  few  seconds  the  glottis  is  completely  closed  ;  the 
face  then  becomes  lead-coloured,  and  the  limbs  are  agitated  by  convulsive 
movements.  According  to  Eihiet  and  Barthez,  the  pulse  is  email,  frequent, 
and  irregular,  and  the  heart's  action  also  irregular  and  tumultuous.  If 
the  child  be  markedly  rickety  a  general  eclamptic  attack  may  supervene, 
or  there  may  be  tonic  contractions  of  all  the  voluntary  muscles,  the  body 
becoming  stiff,  the  limbs  contracted,  and  the  fingers  and  toes  forcibly 
flexed. 

In  new-born  infants,  on  account  of  the  feebleness  of  the  child — for  it  is 
in  weakly  or  prematurely  born  infants  only,  as  far  as  I  have  noticed,  that 
laryngismus  occurs  so  soon  after  birth — the  symptoms  are  quieter.  In 
the  cases  I  have  seen  crowing-breathing  was  absent.  The  lips  were  no- 
ticed to  turn  blue  and  the  face  to  become  livid ;  the  baby  stretched  him- 
self out  stiffly  and  remained  for  a  few  seconds  perfectly  motionless,  with 
flexed  fingers  and  toes.  There  was  complete  immobility  of  the  respiratory 
muscles,  and  he  seemed  as  if  dead.  Then  he  drew  a  deep  sigh  and  the 
attack  was  over.  In  these  cases  the  spasm  appears  to  be  seated  in  the  dia- 
phragm and  external  muscles  of  respiration,  leaving  the  glottis  unaffected  ; 
for  no  symptom  is  noticed  of  narrowing  of  the  rinia.  Obstruction  to 
breathing  seems  to  be  complete.  The  seizure  is  short  aad  rarely  lasts 
longer  than  five  or  at  the  most  ten  seconds. 

In  an  uncomplicated  case  of  laryngismus  stridulus,  i.e.,  in  a  case  where 
the  complaint  consists  of  pure  muscular  spasm,  there  is  no  fever.  Some- 
times, however,  laryngismus  complicates  an  attack  of  pneumonia.  The 
temperature  is  then  high.  These  cases  are  very  serious  and  usually  end 
fatally. 

Even  in  an  uncomplicated  case  death  may  ensue.  If  this  happen  during 
a  paroxysm,  the  face  assumes  an  expression  of  the  utmost  terror  ;  the  eyes 
are  widely  open  and  suffused,  the  pupils  are  dilated,  and  the  eyeballs  seem 
to  project ;  the  complexion  grows  more  and  more  dusky,  sweat  breaks 
out  on  the  forehead,  and  the  pulse  grows  feeble  and  small.  Inspiratory 
efforts  are  at  first  violent,  then  cease ;  the  heart  stops,  and  the  child  falls 


LARYNGISMUS   STRIDIJLrS — SYMPTOMS — DIAGNOSIS.  271 

back  dead.  Death  may  be  preceded  by  general  convulsions.  This  is  the 
result  of  asphyxia  from  too  long-continued  spasm  of  the  inspiratory  mus- 
cles. According  to  Dr.  J.  Solis  Cohen,  incarceration  of  the  epiglottis  is 
apt  to  occur  in  the  more  violent  paroxysms,  and  may  produce  death  by 
suffocation.  The  epiglottis  is  drawn  forcibly  down  by  the  spasmodic  action 
of  the  ary-epiglottidean  muscles,  and  its  free  edge  is  caught  between  the 
posterior  face  of  the  larynx  and  the  wall  of  the  pharynx,  so  as  to  cover  the 
glottis  hke  a  lid  and  completely  occlude  it.  In  such  cases  it  can  be  felt  by 
the  finger  passed  deeply  into  the  child's  throat.  Sometimes  death  takes 
place  still  more  suddenly,  and  the  end  then  resembles  an  attack  of  fatal 
syncope.  The  dusky  face  assumes  a  ghastly  pallid  hue,  the  muscles  gen- 
erally relax,  and  the  patient  is  found  to  be  dead. 

In  other  instances,  where  the  seizures  have  been  violent  and  persistent, 
especially  if  they  have  been  complicated  by  general  convulsions,  the  child 
may  die  more  slowly.  In  most  of  these  cases  extensive  collapse  takes 
place  in  the  lungs.  The  spasmodic  symptoms  subside  but  the  child's  face 
continues  dusky.  His  lips  are  blue,  his  nostrils  work,  he  hes  very  quietly 
breathing  with  rapid,  shallow  inspirations  which  expand  the  chest  very  im- 
perfectly ;  he  gets  more  and  more  livid,  and  after  some  hours  dies  quietly 
or  in  a  final  convulsion. 

Sudden  death  from  asphyxia  may  take  place  early,  even  it  is  said  in  the 
first  attack.  The  slower  death  from  collapse  of  the  lung  is  seldom  seen 
except  in  severe  cases  where  the  child  is  exhausted  by  repeated  and  violent 
paroxysms,  or  where  the  complaint  has  been  complicated  by  general  con- 
vulsions. In  rickety  children  who  are  left  untreated  for  that  disease  the 
spasms  continue  as  long  as  the  faulty  nutrition  to  which  the  disorder  is 
due  remains  unremedied.  The  seizures  may  therefore  go  on  for  months, 
or  even  years,  when  the  parents  are  ignorant  or  careless,  and  the  child  is 
injudiciously  reared.  In  ordinary  cases  the  patient  is  treated  early  and 
soon  recovers.  Children  after  the  second  year  rarely  suffer  from  the  com- 
plaint. I  have,  however,  met  with  it  once  in  a  rickety  little  girl  of  four  and 
a  half  years  old. 

Diagnosis. — In  new-born  babies  laryngismus,  especially  if  it  be  of  that 
variety  which  is  manifested  by  spasm  of  the  diaphragm  and  intercostal 
muscles  without  closure  of  the  glottis,  may  be  mistaken  for  infantile  teta- 
nus. We  may  distinguish  the  two  diseases  by  remarking  that  in  laryngis- 
mus the  temperature  is  normal,  and  that  between  the  attacks  the  muscles 
are  perfectly  relaxed.  This  complete  relaxation  of  the  muscles  is  the  most 
trustworthy  distinguishing  mark,  for  the  temperature  in  very  young  chil- 
dren may  be  raised  by  many  trifling  and  temporary  conditions.  Some- 
times, however,  there  may  be  a  more  serious  comphcation  that  gives  rise 
to  pyrexia.  Thus  I  once  saw  an  infant  of  two  weeks  old  who  suffered  fi'om 
these  attacks,  and  in  whom  there  was  pyrexia  dependent  upon  pericarditis 
with  copious  effusion  into  the  sac  of  the  heart. 

In  older  children  the  case  maybe  mistaken  for  laryngitis  stridulosa. 
Here,  too,  the  absence  of  fever  is  a  very  important  distinction,  if  the  dis- 
ease is  quite  uncomplicated.  But  children  while  cutting  their  teeth  are 
subject  to  frequent  elevations  of  temperature  from  the  natural  process  of 
dentition  ;  and  this  in  the  subjects  of  rickets,  who  cut  their  teeth  late,  may 
be  delayed  far  beyond  the  end  of  the  second  year.  We  should  then  be 
careful  to  satisfy  ourselves  that  the  gums  are  not  swollen,  and  that  there 
is  no  stomatitis  or  other  complication  capable  of  giving  rise  to  fever. 
Moreover,  the  history  and  course  of  the  two  diseases  are  different.  In 
laryngismus  the  spasm  comes  on  quite  suddenly,  lasts  a  few  seconds  or  a 


272  DISEASE   IN   CHILDEEN. 

minute  or  two,  and  tlien  subsides.  Laryngitis  is  preceded  by  cougli  and 
hoarseness ;  the  attacks  of  dyspnoea  are  much  more  prolonged,  and  even 
in  the  intervals  the  breathing  is  more  or  less  oppressed,  the  voice  hoarse, 
and  the  cough  loud  and  clanging.  Again,  stridulous  laryngitis  is  an  acute 
disease,  while  laryngismus  stridulus  is  apt  to  take  on  a  very  acute  course. 
In  laryngismus  there  are  often  tonic  spasms  or  cai-popedal  contractions,  and 
the  disorder  is  often  complicated  by  general  convulsions.  In  laryngitis 
convulsions  are  rare  and  tonic  contractions  are  very  rarely  seen.  Lastly, 
laryngitis  stridulosa,  as  a  rule,  attacks  children  after  the  age  at  which 
they  are  most  susceptible  to  laryngismus,  and  is  not  common  in  infants 
under  two  years  old. 

Prognosis. — In  new-born  infants  the  prospect  is  very  serious,  for  the 
attacks  at  this  early  age  are  very  apt  to  end  fatally.  Persistent  lividity  of 
the  face  or  other  sign  of  collapse  of  the  lung  is  a  symptom  of  very  dan- 
gerous import. 

In  older  children,  if  the  spasm  remains  limited  to  the  respiratory  mus- 
cles, the  prognosis  is  less  serious  than  in  cases  where  the  convulsions,  at 
first  local,  afterwards  become  general.  The  percentage  of  mortahty  has 
been  put  very  high  by  some  writers  ;  but  statistics  gathered  from  pub- 
hshed  cases  alone  are  ajDt  to  be  misleading,  as  only  the  worst  cases  are 
Hkely  to  be  placed  on  record.  The  j)rognosis  depends  in  great  measure 
upon  the  strength  of  the  child  and  the  degTee  of  rickets  which  may  be 
present.  If  there  be  much  softening  of  the  ribs  and  consequent  interfer- 
ence mth  respiration,  there  is  great  danger  of  pulmonary  collapse  taking 
place,  and  the  case  is  a  very  serious  one.  If,  under  these  circumstances 
general  convulsions  ensue,  the  child's  life  is  in  very  imminent  danger. 
Even  in  the  slightest  cases  we  should  speak  guardedly  of  the  patient's 
chances  of  recovery. 

Treatment. — If  the  child  be  seen  during  an  attack,  attempts  should  be 
made  to  excite  vomiting  by  passing  the  finger  into  the  fauces.  Afterwards 
a  sponge  wrung  out  of  hot  water  may  be  apphed  to  the  throat  under  the 
chin.  According  to  M.  Charon,  who  first  proposed  the  remedy,  the  inha- 
lation of  ammonia  is  almost  invariably  successful  in  arresting  an  attack. 
This  physician  adrises  all  mothers  whose  children  are  subject  to  spasm  of 
the  glottis  to  caiTy  a  small  bottle  of  ammonia — ordinary  "  smelling  salts  " 
— about  with  them.  He  relates  the  case  of  a  lady  whose  child  was  always 
rapidly  relieved  by  this  means.  Unfortunately  one  day  the  child  was 
seized  with  an  attack  at  a  time  when  the  remedy  was  not  at  hand, 
and  Avhile  the  mother  Vvas  hui-riedly  searching  for  it  the  child  fell  back 
dead. 

If  the  sufibcative  spasm  be  very  intense,  it  is  well  to  thrust  the  finger 
deeply  into  the  child's  throat,  so  that  the  epiglottis,  if  incarcerated,  as  de- 
scribed by  Dr.  Cohen,  may  be  released.  The  seizure,  however,  in  most 
cases,  is  over  so  quickly  that  there  is  little  time  to  adopt  measures  for 
abridging  it.  But  we  can  at  any  rate  take  steps  to  prevent  a  retui-n  of  the 
paroxysms.  For  this  object  cold  water  bathing  is  indisputably  the  most 
important  and  most  immediately  successful.  The  child  should  be  placed 
naked  in  an  empty  bath  or  large  basin,  and  be  then  rapidly  sponged  all 
over  the  body  with  cold  water.  In  Avinter  he  may  be  made  to  sit  in  hot 
water  during  the  process.  The  bath  should  be  given  three  times  a  day. 
Very  few  cases  of  laryngismus  will  be  found  to  resist  this  treatment.  I 
have  used  it  in  obstinate  cases,  and  to  children  suffering  from  rickets,  with 
the  most  satisfactory  results.  Next  to  cold  bathing  fresh  air  is  of  the 
greatest  service.     The  child,  warmly  dressed,  should  be  taken  regularly 


LAETJSTGISMUS   STRIDULUS— TEEATMENT.  273 

out  of  doors,  and  even  in  cold  weather  should  spend  many  hours  in  the 
open  air. 

While  these  measures  are  being  carried  out,  search  must  be  made  for 
any  source  of  in-itation  which  may  serve  as  an  exciting  cause  of  the 
spasms.  Tense  swollen  gums  should  be  lanced,  the  dietaiy  must  be  re- 
constructed upon  sound  principles,  and  the  condition  of  the  digestive 
canal  must  be  attended  to.  In  many  of  these  cases  the  bowels  are  loose 
with  relaxed  slimy  motions.  If  this  be  so,  a  dose  of  rhubarb  should  be 
given,  and  the  child  should  take  for  a  few  days  five  or  six  grains  of  bicar- 
bonate of  soda  dissolved  in  an  aromatic  water  sweetened  with  glycerine. 
Of  special  drugs  musk  and  belladonna  are  the  most  useful.  The  former 
can  be  given  to  a  child  of  twelve  months  old  in  doses  of  one-third  of  a 
grain  every  six  hours,  and  will  be  found  to  have  a  powerful  influence  in 
checking  the  tendency  to  spasm.  Belladonna  to  be  of  service  must  be 
given  in  sufficient  doses.  A  baby  of  twelve  months  old  will  take  well  fif- 
teen drops  three  times  in  the  day.  Mr.  Stewai-t  of  Barnsley,  speaks 
highly  of  chloral  in  the  treatment  of  spasm  of  the  glottis,  and  recom- 
mends two  and  a  half  grains  to  be  given  to  a  child  of  twelve  months  old 
three  times  a  da_y. 

In  new-born  babies,  for  whom  cold  sponging  is  inadmissible,  musk  is  a 
very  important  remedy.  One-fourth  of  a  gTain  can  be  given  three  times 
a  day,  suspended  in  mucilage.  It  can  be  combined  with  ten  drops  of  tinc- 
ture of  belladonna  if  thought  desirable. 

If  the  child  is  markedly  rickety,  iron  and  cod-liver  oil  should  be  given 
as  soon  as  the  state  of  his  digestive  organs  is  sufficiently  improved  to  make 
the  use  of  the  tonic  desirable.  Ii'on  wine  is,  perhaps,  the  best  form  in 
which  that  drug  can  be  administered,  for  the  alcohol  it  contains  is  an  ad- 
dition of  great  value  »to  weakly  children.  Great  care  must  be  taken  in 
these  cases  that  the  child  is  not  overfed  with  farinaceous  foods  which  con- 
tribute little  to  his  general  nutrition  while  they  overload  him  with  un- 
healthy fat.  They  are  also  very  apt  to  turn  acid  in  the  stomach  and  favour 
catarrhal  derangements.  No  mention  has  been  made  of  bromide  of  po- 
tassium, for  in  this  complaint  I  hold  the  drug  to  be  of  very  inferior  value, 
and  place  it  far  below  musk  in  its  powers  as  an  antispasmodic. 
18 


CHAPTER  III. 

TONIC   CONTRACTION   OF   THE   EXTREMITIES. 

Tonic  contraction  of  the  extremities,  or  tetany,  is  sometimes  met  with  in 
young  children,  most  commonly  in  the  subjects  of  reflex  con-vTilsions  or 
laryngismus  stridulus.  The  contraction  occupies  the  muscles  of  the  limbs, 
especially  those  of  the  hands  and  feet,  and  may  be  continuous,  remittent, 
or  intermittent. 

Caitsafion. — Tonic  contraction  appears  to  be  one  of  the  many  forms  of 
reflex  disturbance  to  which  rickety  and  excitable  childi'eu  are  so  peculiarly 
prone.  The  disorder  rarely  attacks  a  sturdy  subject.  It  is  most  commonly 
met  with  in  young  patients  whose  nutrition  is  imperfect  either  fi'om  in- 
judicious management  or  natural  delicacy  of  constitution,  and  appears  to 
be  predisposed  to  or  excited  by  digestive  derangements  and  other  forms 
of  irritation.  Thus  a  little  girl  of  five  years  old,  who  had  recovered  under 
my  own  observation  from  tubercular  peritonitis,  biit  had  remained  very 
delicate  and  Hable  to  gastric  and  intestinal  troubles,  one  day  swallowed  a 
part  of  an  orange.  She  was  seized  shortly  afterwards  with  severe  j^ains  in 
the  belly,  and  passed  a  few  loose,  unhealthy  motions.  At  the  same  time 
the  fingers  became  firmly  clenched,  with  the  thumbs  inverted  and  the  wrists 
flexed.  In  this  state  she  remained  for  forty-eight  horu's,  in  spite  of  active 
treatment  by  injections  and  laxatives.  At  the  end  of  this  time  a  large 
enema  brought  away  a  mass  of  orange  pulp.  The  child  was  at  once  re- 
lieved, and  the  rigid  contractions  of  the  muscles  ceased  from  that  moment. 
Similar  instances  have  been  recorded  in  which  a  constipated  state  of  the 
bowels  has  been  a  cause  of  the  phenomenon,  and  other  sources  of  dis- 
turbance and  excitement,  such  as  pleurisy,  pneumonia,  diarrhoea,  intestinal 
worms,  the  irritation  of  uric  acid  calculi,  and  teething  have  been  quoted 
as  exciting  causes  of  this  painful  affection.  The  age  at  which  children  are 
most  liable  to  be  attacked  is  between  the  first  and  third  year.  The  disor- 
der is  said  sometimes  to  affect  young  girls  shortly  before  puberty,  and  in 
such  cases  is  attributed  on  the  continent  of  Europe,  where  tetany  seems  to 
be  more  common  than  in  this  country,  to  the  influence  of  cold  and  damp. 

Symptoms. — A  child  who  has  been  for  some  time  in  a  weakly  state,  and 
is,  perhaps,  in  the  majority  of  cases,  the  subject  of  mild  rickets,  all  at  once 
cries  with  pain  in  the  extremities,  and  it  is  noticed  that  these  parts  are 
contracted.  Often  the  contraction  is  found  to  succeed  to  a  fit  of  convul- 
sions or  an  attack  of  laryngeal  spasm  ;  but  it  persists  after  these  are  at  an 
end.  The  muscvQar  sjDasm  may  affect  both  hands  and  feet,  or  be  noticed 
first  in  the  fingers,  and  spread  thence  to  the  hand  and  wrist,  the  ankle  and 
the  toes.  When  fully  developed  the  hand  is  f oimd  to  be  flexed  at  the 
wrist,  and  the  thumb  to  be  firmly  inverted  into  the  palm.  The  fingers  may 
be  rigidly  clenched  u^Jon  the  thumb,  or  slightly  separated  and  perfectly 
straight  except  for  some  slight  flexing  of  the  last  joint.  The  ankles  are 
often  extended  and  the  toes  firmly  flexed.  In  a  few  cases  redness  and 
swelling  in  the  neighboui-hood  of  the  joints  have  been  noticed.     The  con- 


TETANY— CAUSATION — DIAGNOSIS.  275 

traction  in  most  cases  seems  to  be  painful.  Infants  cry  repeatedly,  and 
older  children  complain  of  pains  shooting  along  the  course  of  the.  nerves. 
The  muscles  are  in  a  state  of  rigid  contraction.  In  pronounced  cases,  not 
only  can  the  muscles  of  the  leg,  such  as  the  gastrocnemii  and  peroneii,  and 
of  the  forearm  be  felt  to  be  firm,  but  the  act  of  manipulating  them  in- 
ci-eases  their  tendency  to  become  rigid.  Pressure  may  even  induce  tonic 
contractions  in  muscles  otherwise  free  from  rigidity,  such  as  the  pectorals, 
the  muscles  of  the  neck,  and  those  of  the  abdomen.  In  a  severe  case  re- 
corded by  Dr.  Cheadle — in  a  boy  two  years  old — even  the  muscles  of  the 
face  were  in  a  state  of  abnormal  excitability,  for  irritation  of  the  skin  just 
in  front  of  the  left  parotid  region  caused  twitching  of  the  orbicularis  pal- 
pebrarum, the  levator  alee  nasi,  and  the  levator  anguli  oris.  The  same 
phenomenon  was  also  seen,  although  to  a  less  degree,  on  the  right  side  of 
the  face.  There  was,  in  addition,  some  difficulty  in  swallowing,  especially 
when  liquids  were  taken. 

When  the  attacks  follow  a  convulsive  seizure  they  may  be  accompanied 
by  a  temporary  paralysis,  such  as  is  a  not  uncommon  consequence  of 
eclamjDsia  (see  page  280).  Sometimes  the  contractions  are  more  exten- 
sive. Thus  the  muscles  of  the  trunk  are  occasionally  affected.  Eilliet 
refers  to  the  case  of  a  delicate  little  girl,  aged  twelve  years,  in  whom  the 
tonic  rigidity  of  the  extremities  was  accompanied  by  opisthotonos  with 
extreme  retraction  of  the  head,  and  at  times  intermittent  contractions 
limited  to  the  back  were  noticed,  closely  resembling  tetanus  in  character  ; 
but  the  jaws  were  not  affected,  as  they  invariably  are  in  that  disease.  The 
disorder  lasted  for  a  month.  In  other  cases,  according  to  the  same  au- 
thority, the  spasms  may  be  more  limited  and  affect  the  hip  or  one  side  of 
the  neck.  The  disease  appears  to  be  more  severe  upon  the  continent  of 
Europe  than  it  is  in  England.  In  the  milder  form  common  in  this  coun- 
try the  contractions  are  invariably  bilateral,  and  affect  the  corresponding 
muscles  of  the  two  sides.  As  long  as  they  continue,  walking  is  impossible, 
and  the  child  can  hold  nothing  in  his  hand.  In  the  slighter  forms  the 
contractions  are  remittent,  and  occasionally  cease  completely.  In  severe 
cases  little  variation  is  seen  in  the  rigidity,  and  it  persists  during  sleep. 
Even  complete  ansesthesia  from  chloroform  produces  no  relaxation  of  the 
tonic  spasm.  Sensation  is  unaffected ;  reflex  excitability  is  normal ;  the 
temperature  is  natural  or  even  below  the  level  of  health  and  the  child's 
intelligence  remains  perfect.  In  Dr.  Cheadle's  case  the  muscles  responded 
well  to  both  the  continued  and  interrupted  current.  The  tonic  contractions 
are  rarely  the  only  nervous  symptoms  present.  Often  they  alternate  with 
other  forms  of  nervous  spasm.  The  child  may  be  subject  to  laryngismus 
stridulus,  or  may  be  readily  thrown  into  convulsions  by  any  passing  irrita- 
tion. In  many  cases,  as  has  been  said,  the  contractions  succeed  to  some  such 
form  of  nervous  seizure,  and  sometimes  an  intermittent  squint  is  noticed. 

In  most  cases,  in  addition,  symptoms  of  intestinal  or  other  derangement 
are  present.  Diarrhcea  is  one  of  the  commonest  of  those  symptoms  ;  and, 
indeed,  the  nervous  disorder  has  been  known  to  disappear  as  the  condition 
of  the  bowels  improved.  The  duration  of  tetany  is  very  variable.  It  may 
last  a  few  days  or  persist  for  weeks.  It  usually  becomes  intermittent  before 
it  finally  disappears.    After  ceasing  for  a  time  it  not  unfrequently  returns. 

Diagnosis. — This  form  of  nervous  spasm  is  readily  recognised.  Tonic 
contractions  occur  in  a  child  whose  nutrition  is  impaired  either  from  inju- 
dicious management,  from  gastro-intestinal  derangement,  or  from  the  re- 
cent presence  of  acute  disease.  Often  he  is  the  subject  of  rickets,  and  has 
already  shown  a  tendency  to  other  forms  of  nervous  derangement.     Tetany 


276  DISEASE  IN   CHILDEEN. 

is  bilateral  and  symmetrical.  It  occasions  no  elevation  of  temperature  and 
is  accompanied  by  no  clouding  of  the  intellect.  These  qualities,  combined 
with  the  tendency  to  nervous  spasm,  and  the  evident  connection  of  the  attack 
vdth  some  form  of  peripheral  h-ritation,  will  serve  to  exclude  cerebral  dis- 
ease. In  the  severe  form,  which  is  accompanied  by  opisthotonos  and  tetan- 
oid spasms,  the  history  of  the  attack,  the  normal  temperature,  and  the  en- 
tire absence  of  stiffness  of  the  jaws  will  be  sufficient  to  exclude  tetanus. 

P7'ognosis. — Tetany  is  merely  a  symptom  which  has  no  gravity  what- 
ever ;  and  the  prospects  of  the  patient's  recovery  of  health  deiDend  upon 
causes  quite  independent  of  the  nervous  spasm.  As  the  children  in  whom 
tetany  occurs  are  often  the  subjects  of  a  chronic  intestinal  derangement, 
and  are  in  many  cases  distressed  by  frequent  attacks  of  laryngismus  stridu- 
lus, they  may  possibly  succumb  ;  but  in  estimating  the  patient's  chances 
of  recovery  the  tonic  rigidity  of  the  extremities  may  be  quite  excluded 
from  our  calculations. 

Treatment. — Our  first  care  in  the  treatment  of  this  complaint  must  be 
to  attend  to  any  disordered  condition  which  may  be  present  interfering 
with  nutrition,  and  acting  as  an  irritant  to  the  nervous  system.  Gastro- 
intestinal derangements  must  be  checked  ;  constipated  bowels  must  be  re- 
lieved ;  the  diet  must  be  regulated  to  suit  the  needs  of  the  system  (see 
Infantile  Atrophy,  Chronic  Diarrhoea,  etc. )  ;  and  if  rickets  be  present,  meas- 
ures must  be  taken  at  once  to  arrest  its  progress.  In  all  cases,  indeed, 
the  general  treatment  recommended  for  laryngismus  stridulus  and  rickets, 
viz.,  fresh  air,  good  food,  cleanliness,  and  the  administration  of  iron  wine 
and  cod-liver  oil,  is  of  equal  service  in  this  disorder.  Frictions  and  warm 
baths  seem  also  to  have  a  beneficial  influence. 

In  obstinate  cases  special  steps  are  required  to  relieve  the  tonic  rigid- 
ity. This  form  of  spasm  will  often  refuse  to  yield  to  measures  which  have 
the  power  of  readily  controlling  the  nervous  disorders  with  which  tetany 
is  allied.  Chloroform  puts  an  immediate  stop  to  an  eclamptic  seizure, 
but  has  no  power  of  relaxing  the  rigidly  contracted  muscles  of  tetany ; 
and  chloral  which  is  so  valuable  in  arresting  the  spasm  in  laryngismus 
stridulus  is  given  in  this  neurosis  without  any  beneficial  result.  Bromide 
of  potassium  and  musk  appear  to  be  equally  useless.  In  Dr.  Cheadle's 
case,  before  referred  to,  chloroform,  chloral,  and  bromide  of  potassium  wei"e 
given  without  any  success  ;  but  the  contractions  yielded  after  the  treat- 
ment had  been  changed  to  Calabar  bean  with  cod-liver  oil  and  iron  wine. 
One  thirty- sixth  of  a  grain  of  the  bean  was  given  three  times  a  day.  1'he 
dose  was  gradually  increased  to  one-eighth  before  any  effect  was  produced. 
A  notable  diminution  in  the  stiffness  was  then  observed.  Afterwards  the 
dose  was  increased  to  one-fifth,  later  to  one-fourth,  and  lastly  to  one-thii'd 
of  a  gTain  three  times  a  day.  The  boy  was  well  seven  weeks  after  begin- 
ning to  take  the  remedy. 

Although  the  bean  appears  in  this  case  to  have  had  a  decided  influence 
over  the  spasm,  it  must  be  noted  that  the  child  began  at  the  same  time  to 
take  iron  wine  and  cod-liver  oil ;  and  that  although  the  principal  improve- 
ment occurred  after  the  dose  had  been  pushed  to  one-sixth  of  a  grain,  it 
followed  two  days  after  the  important  addition  of  pounded  raw  meat  had 
been  made  to  the  child's  diet.  The  Calabar  bean,  no  doubt,  deserves  a 
more  extended  trial  in  these  cases  of  tonic  rigidit3^  StiU,  in  the  interest- 
ing case  referred  to  it  is  doubtful  what  degree  of  improvement  can  be  cor- 
rectly attributed  to  this  remedy  ;  for  the  alcohol,  the  cod-liver  oO,  and  the 
improved  diet  must  have  taken  a  sensible  share  in  bringing  about  the 
child's  recovery  of  health. 


CHAPTER  TV. 

CONVULSIONS. 

The  commotion  in  tlie  nervous  system  which  goes  by  the  name  of  eclamp- 
sia, or  a  fit  of  convulsions,  is  a  common  phenomenon  in  infancy,  and  is 
sometimes  seen  in  early  childhood.  The  seizure  depends  upon  an  ex- 
alted excitability  of  the  reflex  centres  seated  in  the  pons  and  medulla  ob- 
longata, but  is  seldom  attended  by  changes  in  those  parts  capable  of  being 
detected  on  examination  of  the  dead  body.  The  disturbance  is  essentially 
a  symptom,  and  may  be  produced  by  a  variety  of  causes.  Irrespective, 
then,  of  the  immediate  danger  to  Ufe,  the  phenomenon  may  be  of  serious 
moment  or  of  trifling  consequence  according  to  the  cause  which  has  in- 
duced it.  It  is,  therefore,  of  great  importance  to  ascertain  its  mode  of 
origin,  for  only  by  this  means  can  we  speak  with  any  certainty  as  re- 
gards the  influence  which  the  attack  is  likely  to  have  upon  the  future  well- 
being  of  the  child. 

It  is  during  the  first  two  years  of  life  that  the  tendency  to  this  form  of 
nervous  derangement  is  most  active.  At  this  period  of  childhood  the  ner- 
vous system  of  the  infant,  although  immature,  is  undergoing  rapid  devel- 
opment, and  the  reflex  centres  respond  briskly  to  every  form  of  peripheral 
irritation.  The  tendency  to  eclampsia  is  not,  however,  confined  to  this 
age.  Convulsions  may  even  affect  the  infant  in  the  womb.  Early  death 
of  the  foetus  and  premature  labotu-  can  be  sometimes  attributed  to  this 
cause,  and  it  is  to  this  accident  that  some  varieties  of  congenital  deformity 
have  been  referred — those  which  are  characterised  by  permanent  contrac- 
tion of  special  muscles.  After  birth  the  proneness  to  convulsions  may  con- 
tinue for  a  longer  or  shorter  time,  according  to  the  natural  sensitiveness  of 
the  nervous  system  to  external  impressions.  It  is  therefore  much  more 
persistent  in  some  children  than  in  others,  and  may  endure  in  exceptional 
cases  to  the  ninth  or  tenth  year. 

Causation. — There  are  certain  conditions  which  predispose  a  child  to 
convulsions.  Thus  the  liability  to  eclamptic  seizures  sometimes  runs  in 
families,  so  that  all  the  children  born  of  certain  parents  are  found  to  suffer 
from  these  attacks.  In  other  cases  the  tendency  is  confined  to  certain  in- 
dividuals of  the  family,  or  even  to  one  sex.  Thus-  all  the  boys  may  have 
convulsions  while  the  girls  escape.  Again,  in  rickets  there  is  a  special 
convulsive  tendency  which  is  very  remarkable,  and  a  large  number  of  the 
cases  of  reflex  convulsions  are  found  to  occur  in  children  with  this  consti- 
tutional condition.  When  the  predisposition  exists  very  slight  causes — 
causes  often  so  trifling  as  to  escape  recognition — may  induce  the  attacks. 

Within  certain  limits  the  state  of  a  child's  nutrition  does  not  appear  to 
afiect  his  susceptibility  to  convulsive  seizures.  A  strong  child  and  a  weak 
one  may  be  equally  prone  to  suffer  from  this  nervous  disturbance.  When, 
however,  an  infant  is  gi-eatly  reduced  by  long-continued  interference  with 
nutrition,  a  remarkable  difference  is  noticed  in  his  sensibility  to  nervous 
impressions.     Not  only  is  there  no  exaltation  of  reflex  function,  but  the 


278  DISEASE  i:;^   CHILDEEjS^. 

normal  excitability  of  the  reflex  centres  is  climinislied  or  annulled.  There- 
fore in  a  child  so  enfeebled  convulsions  are  seldom  of  reflex  origin,  but 
usually  indicate  grave  cerebral  disease. 

The  exciting  causes  of  the  nervous  commotion  are  very  various  : 

Tme  reflex  con^odsions  arise  fi-om  peripheral  ii'ritation.  Injuries  to  the 
skin  from  pricks,  burns,  and  wounds  ;  ii-ritation  of  the  alimentary  canal 
from  indigestible  food,  hard  fsecal  masses,  or  parasitic  worms  ;  of  the  gums 
from  inflammation  and  sweUing  during  the  cutting  of  a  tooth  ;  of  the  ear 
from  collections  of  wax,  the  presence  of  a  foreign  body  in  the  auditory 
meatus,  or  inflammation  of  the  tympanic  cavity  ;  retention  of  uiine  ;  sud- 
den chilling  of  the  sioi'face  fi'om  exposure  ;  violent  emotions,  such  as  ter- 
ror— all  these  causes  may  set  up  convulsions  in  certain  subjects. 

Ii'ritation  affecting  the  mucous  membrane  of  the  stomach  and  intestine, 
and  according  to  some  authors  iiTitation  within  the  ear,  seem  to  be  the 
most  common  exciting  causes  of  reflex  convulsions.  In  hand-fed  babies 
indigestion  is  a  famihar  occuiTence,  and  the  distui'bance  set  up  by  a  mass 
of  undissolved  curd  or  other  ii'ritant  may  sj)eeclily  culminate  in  an  attack 
of  eclampsia.  Again,  otitis  is  a  more  common  disease  of  infancy  than  is 
usually  supposed.  It  is  often  a  direct  consequence  of  dental  m'itation, 
and  occurs  with  such  frec[uency  as  to  constitute  one  of  the  more  common 
compHcations  of  dentition.  According  to  Dr.  T^'oakes  the  inflamed  and 
swollen  gum  is  a'  source  from  which  ii-ritation  is  conveyed  to  the  otic 
ganglion,  and  thence  is  deflected  to  the  vessel  supplying  the  tympanic 
membrane.  Acute  congestion  of  the  membrane  thus  occasioned  is  a  source 
of  extreme  pain  ;  and  if  the  irritation  persist,  suppuration  in  the  tympanic 
cavity  may  follow.  Inflammatory  tension  of  the  gum  alone  may  set  up  the 
eclamptic  attack  ;  and  the  secondary  distui'bance  in  the  ear  is  a  fi'uitful 
soui'ce  of  such  seizui'es. 

Eclamptic  attacks  are  common  in  the  child  at  the  onset  of  acute  illness, 
and  correspond  to  the  rigor  which  usually  introduces  the  febi'ile  move- 
ment in  older  persons.  These  seizures  must  not  be  attributed  du'ectly  to 
the  pyrexia,  for  it  is  improbable  that  the  mere  elevation  of  temperature  is 
sufficient  to  produce  them.  The  more  severe  the  attack  and  the  younger 
and  more  impressible  the  patient,  the  more  likely  are  convulsions  to  be 
seen.  These  attacks  are  seldom  dangerous,  but  the  eclamptic  fits  which 
occur  at  a  later  stage  of  the  same  diseases  arise  from  a  different  cause  and 
have  a  far  graver  meaning. 

Another  class  consists  of  the  convulsions  which  ai'e  induced  by  imper- 
fect aeration  of  blood.  These  constitute  the  less  serious  attacks  which 
sometimes  arise  in  the  course  of  pertussis  after  a  prolonged  paroxysm  of 
cough,  and  often  precede  death  in  cases  of  extensive  collapse  of  the  lung.- 

Congestion  of  the  brain  is  often  quoted  as  one  of  the  causes  of  convul- 
sions, and  no  doubt  fatal  fits  of  eclampsia  are  fi'equently  associated  \rith  a 
hyperaemic  state  of  the  cerebral  vessels.  The  chief  factor  in  such  cases, 
both  of  the  congestion  and  the  fits,  may,  as  Dr.  Bastian  has  suggested,  be 
minute  embolisms  or  thromboses  in  the  small  arteries  and  capillaries  of 
the  brain.  In  the  fatal  convulsions  which  sometimes  abru^^tly  terminate 
an  attack  of  whooping-cough  congestion  of  the  brain  is  generally  present, 
and  is  often  dependent  in  such  cases  upon  thrombosis  of  the  cranial  sinuses. 

An  exactly  opposite  state  of  the  cerebral  vessels  may  induce  the  same 
symptom.  The  anaemia  of  brain  which  results  from  profuse  haemorrhage 
or  exhausting  discharges,  such  as  an  attack  of  acute  diarrhcea,  is  often  in- 
dicated ,by  a  convulsive  seizui'e.  It  is,  however,  worthy  of  note  that  an 
ec^ual  degree  of  prostration  slowly  established  by  a  chi'onic  intestinal  de- 


coisrvtrLSiojsrs — causation — symptoms.  279 

rangement  is  not  followed  by  the  same  consequences,  the  excitability  of 
tlie  nervous  centres  being  then  diminished  instead  of  exalted. 

Lastly,  toxic  causes  may  induce  convulsive  seizures.  Ursemic  convul- 
sions belong  to  this  class,  and  also  the  eclamptic  attacks  which  are  com- 
mon in  children  who  live  in  malarious  districts.  Lead  in  the  system  may 
produce  the  same  result.  Infants  seem  to  be  very  susceptible  to  the  influ- 
ence of  lead  given  medicinally.  I  have  long  ceased  to  make  use  of  this 
remedy  in  the  treatment  of  the  diarrhceas  of  young  children,  as  I  have 
several  times  seen  convulsions  follow  its  employment,  and  the  attack  has  ap- 
peared to  me  in  some  cases  to  be  directly  excited  by  the  use  of  this  agent. 

Convulsions  arising  from  cerebral  disease  have  been  omitted  from  the 
above  classification,  as  partaking  more  of  the  nature  of  epileptic  attacks 
than  of  true  eclampsia.  Keference  must,  however,  be  frequently  made  to 
them  in  discussing  the  subject  of  convulsive  seizures,  for  it  is  of  the  ut- 
most importance  in  every  case  where  a  child  is  taken  with  a  fit  to  be  able 
to  exclude  centric  causes  from  consideration. 

Symptoms. — The  convulsive  seizures  may  come  on  suddenly  or  be  pre- 
ceded by  symptoms  of  nervous  excitability  which  are  more  or  less  obvious. 
Such  phenomena  are  often  called  by  nurses  "inward  fits."  They  are  not 
invariably  followed  by  a  convulsion.  Indeed,  as  a  rule  perhajDS,  they  pasa 
off  after  a  time,  especially  if  they  are  the  consequence  of  digestive  trouble, 
and  the  infant's  placidity  of  manner  returns.  In  other  cases  they  become 
more  and  more  pronounced,  and  culminate  in  an  attack  of  eclamptic 
spasms.  Thus  the  child  is  unusually  disturbed  in  his  sleep.  He  often 
starts  and  twitches.  His  eyelids  may  only  partially  close,  and  he  wakes 
easily,  starting  up  at  the  slightest  touch.  When  awake  he  is  restless  and 
fretful.  His  senses  seem  unusually  acute,  so  that  loud  noises  frighten 
him.  He  changes  colour  frequently.  His  face  has  a  curious  expression, 
the  eyeballs  are  often  directed  upwards,  and  his  thumbs  may  be  twisted 
inwards  across  the  palms.  .  After  these  symptoms  have  continued  for  a 
variable  time — often  for  several  days — the  child  is  all  at  once  noticed  to  be 
unusually  quiet.  He  stares  with  a  peculiar  fixed  look,  and  his  attention 
cannot  be  diverted  to  his  toys.  Then,  suddenly,  the  fit  begins.  The  child 
gets  quite  stiff,  his  head  is  retracted,  his  arms  and  legs  are  rigidly  extended, 
his  eyes  are  turned  upwards,  and  he  ceases  entirely  to  breathe.  In  a  few 
seconds  the  tonic  rigidity  is  replaced  by  clonic  spasms.  The  face  becomes 
intensely  congested,  the  eyelids  are  widely  open,  and  the  eyeballs  are 
drawn  upwards  and  to  one  side,  and  are  twitched  rapidly  in  different  direc- 
tions. The  muscles  of  the  face  work,  the  tongue  may  be  seized  and  bit- 
~ten  by  the  teeth,  and  froth,  perhaps  tinged  with  blood,  may  appear  upon 
the  lips.  The  muscles  of  the  limbs  are  thrown  into  the  same  spasmodic 
action,  and  more  or  less  pronounced  twitching  affects  the  arms  and  legs, 
sometimes  even  down  to  the  fingers  and  toes.  Consciousness  is  comj)letely 
lost.  The  skin  is  often  covered  with  a  profuse  sweat,  and  in  many  cases 
the  sphincters  are  relaxed,  so  that  there  is  involuntary  passage  of  urine  and 
fseces.  During  the  clonic  spasms  the  breathing  is  not  suspended,  but 
there  are  jerking  movements  of  the  resj)iratory  muscles.  After  some  time 
the  spasms  become  less  violent.  The  face  then  changes  from  dusky  red 
to  a  deathly  pallor,  the  muscles  relax,  the  child  often  gives  a  long  sigh, 
and  the  attack  is  at  an  end. 

The  spasmodic  movements  are  usually  general  and  involve  both  sides 
of  the  body,  although  one  side  is  often  more  actively  convulsed  than  the 
other.  Sometimes  they  ai'e  partial,  and  may  be  limited  to  one  or  both 
limbs  on  one  side  of  the  body,  to  the  two  arms,  or  even  to  one  side  of  the 


2S0  DISEASE   I^S"   CHILDEEN. 

face.  The  eyes  are  almost  always  inyolved  in  the  convulsion.  The  fit 
lasts  for  a  time  varying  from  a  few  minutes  to  several  hours.  In  the 
longer  fits  there  are  intervals  of  more  or  less  complete  remission,  and  some- 
times the  so-called  fit  consists  of  a  series  of  eclamptic  seizures  with  short 
intervals  of  quiet.  In  rare  cases  death  takes  place  in  the  fit  from  asphij-xia. 
As  a  rule,  the  child  sleeps  after  the  seizure  has  come  to  a  close,  and  may 
wake  to  all  appearance  quite  weU.  "WTien  the  fit  is  repeated  several  times 
the  child  is  di'owsy  for  a  time  between  the  attacks,  but  the  sleepiness 
passes  off  in  a  few  houi's.  As  long  as  any  signs  of  abnormal  excitabihty  of 
the  neiwous  system  continue,  and  symptoms  characteristic  of  the  condition 
described  as  "inward  fits  "remain,  we  may  anticipate  a  renewal  of  the  con- 
vulsive seizures.  It  is  not  until  all  restlessness,  startings,  twitchings,  etc., 
have  disappeared  that  our  aj)prehensions  can  be  laid  aside. 

Some  loss  of  motor  power  may  be  noticed  after  the  fit  is  at  an  end. 
In  cases  of  pure  eclampsia  this  is  a  very  temporary  phenomenon,  and 
only  occurs  when  the  seizru-es  have  been  very  violent  and  protracted.  It 
is  probably  due  to  exhaustion  of  nervous  power  and  disappears  completely 
after  a  day  or  two.  Any  signs  of  permanent  interference  with  nerve-force, 
such  as  local  muscular  weakness,  contractions,  or  choreic  movements,  are 
usually  taken  to  indicate  some  organic  central  cause  for  the  convulsion. 
It  is  possible,  however,  that  these  symptoms  may  be  the  consecjuence  of 
the  seizure  ;  for  severe  cerebral  congestion  induced  by  intense  and  pro- 
tracted eclampsia  may  give  rise  to  htemorrhage  into  the  brain  or  arachnoid. 
Certainly  I  have  known  cases  of  convulsions  occurring  in  children  as  a 
result  of  some  temporary  iiiitant  to  be  followed  by  paralysis  -with  contrac- 
tion of  muscle,  and  have  thought  that  in  such  cases  the  cerebral  lesion 
might  have  been  secondary  to  the  eclamptic  attack.  There  seems  Httle  rea- 
son to  doubt  that  sometimes  congestion  of  brain,  with  serous  effusion  suf- 
ficient in  quantity  to  flatten  the  convolutions,  may  result  fi'om  an  eclamp- 
tic attack,  and  give  Tise  to  squinting,  di-owsiiiess,  and  death. 

A  rickety  httle  gii-l,  aged  twelve  months,  who  had  cut  only  two  teeth, 
was  C|uite  well  until  January  7th,  when  she  was  weaned.  She  then  became 
very  fretful  and  vomited  her  food.  At  the  same  time  an  eruption  of  small 
red  spots  appeared  on  her  arms  and  face.  On  January  9th  the  child  had 
two  fits,  ill  which  she  "  went  stiff  and  worked  her  arms  about."  On  Janu- 
ary lltia  she  had  a  thu-d  fit  and  then  began  to  squint. 

When  I  saw  the  child,  on  January  17th,  she  was  lying  with  her  eyes 
closed  ;  the  right  eye  was  turned  inwai'ds  with  convergent  sqmnt ;  the  pu- 
pils were  ec[ually  dilated,  and  acted  well  -with  light ;  there  was  no  discharge 
from  either  ear  ;  the  face  was  pale,  but  flushed  upon  pressure  of  the  skiu  ; 
there  was  no  paralysis  or  contraction  ;  the  thumbs  were  not  twisted  in- 
wards, nor  were  the  toes  flexed.  When  the  abdomen  was  compressed 
the  child  made  uneasy  movements.  She  was  evidently  not  unconscious, 
but  seemed  drowsy.  The  heart  and  lungs  were  healthy.  The  child  was 
preparing  to  cut  the  upper  incisors,  and  the  gums  were  very  full  and 
tense.  Pulse,  160,  regular ;  respii-ation,  of  Cheyne-Stokes  type,  40  ;  tem- 
peratui'e,  99°. 

The  patient  was  ordered  a  mercurial  purge,  and  bromide  of  potassium 
was  given  ;  but  the  di-owsiness  deepened  into  stupor,  and  she  died  on 
January  19th.  Her  temperature  rose  every  night  to  101^.  Half  an  hour 
before  death  it  was  99.4"". 

On  examination  of  the  body  the  dm'a  mater  was  noticed  to  be  very 
tense,  and  the  brain  bulged  through  slits  in  the  membrane.  There  was 
great  venous  congestion  of  the  pia  mater,  and  the  convolutions  were  flat- 


CONVULSIONS — DIAGNOSIS.  281 

tened.  On  removing  the  brain  about  two  ounces  of  sanguinolent  fluid 
were  left  at  the  base  of  the  skull,  and  on  section  much  fluid  escaped  from 
the  lateral  ventricles.  Nothing  but  congestion  of  the  brain  was  noticed. 
There  was  no  loss  of  consistence  ;  the  membranes  were  not  thickened,  nor 
had  they  lost  their  pearly  appearance  ;  there  was  no  lymph  effused,  and  no 
gray  granulations  could  be  detected.  There  was  a  mass  of  enlarged  glands 
at  the  bifurcation  of  the  trachea.  The  lungs  and  heart  were  healthy. 
Unfortunately  the  cranial  sinuses  were  not  opened. 

In  this  case  it  seems  clear  that  the  post-mortem  appearances  were  sec- 
ondary to  the  convulsions.  The  nervous  symptoms  themselves  seem  to 
have  been  the  consequence  of  reflex  irritation  from  the  state  of  the  gums, 
combined  with  irritation  of  the  stomach  from  unsuitable  food,  both  oc- 
curring in  a  child  of  rickety  constitution.  The  red  spots  spoken  of  were 
strophulous,  resulting  from  the  indigestion. 

Sometimes  loss  of  speech  and  even  imbecility  have  been  known  to  follow 
upon  an  attack  of  convulsions.  In  such  cases,  no  doubt,  some  profound 
cerebral  lesion  has  induced  the  fit  or  been  caused  by  it. 

Diagnosis. — In  every  case  of  convulsions  we  should  examine  the  patient 
very  carefully  for  signs  of  disease  of  the  brain  or  its  membranes,  more 
especially  as  the  first  question  usually  asked  by  the  parents  after  their  first 
excitement  and  alarm  have  subsided  relates  to  the  possibility  of  any  affec- 
tion of  the  brain.  In  infants  of  twelve  months  old  or  under,  if  the  child 
be  fat  and  robust,  the  fit  is  in  all  "probability  reflex  ;  if  he  be  under-nour- 
ished, weakly,  and  wasted,  i.e.,  in  that  condition  where  all  reflex  excitabil- 
ity is  practically  in  abeyance,  the  convulsion  is  no  doubt  the  consequence 
of  an  intracranial  lesion.  In  a  weakly  wasted  infant  by  far  the  most  com- 
mon cause  of  a  convulsive  seizure  is  general  tuberculosis  with  secondary 
tubercular  meningitis. 

The  character  of  the  flt  itself  will  give  some  indication  valuable  in  diag- 
nosis. Cerebral  convulsions  are  often  j)artial.  Therefore,  if  the  spasms  are 
limited  to  one  side  of  the  body  or  one  limb,  we  should  search  carefully  for 
signs  of  cerebral  disease.  Paralysis  of  the  face  remaining  after  the  end  of 
an  attack  is  indicative  of  a  cerebral  lesion.  Thus,  drawing  of  the  mouth  to 
one  side,  ptosis,  or  inequality  of  pupils  are  symptoms  never  seen  in  true 
uncomphcated  eclampsia.  .A.  squiut  jDcrsisting  after  the  convulsion  has 
passed  off  must  be  regarded  with  anxiety  ;  for  although  not  necessarily  a 
grave  symptom,  it  is  often  indicative  of  a  serious  lesion  ;  and  if  accompanied 
by  signs  of  heaviness,  or  tendency  to  stupor,  must  be  looked  upon  as  an 
unfavourable  omen.  Again,  convulsions,  general  or  partial,  without  loss  of 
consciousness,  should  lead  us  to  suspect  disease  of  the  brain.  Another  im- 
portant symptom  is  the  condition  of  the  child  after  the  attack.  In  true 
eclampsia  consciousness  is  recovered  quickly  after  the  seizure  ;  and  if  any 
drowsiness  remain,  it  is  over  in  a  few  hours.  Signs  of  persistent  stupor  or 
dulness  of  the  senses  would  point  to  a  cerebral  lesion.  Mere  temporary 
loss  of  power  in  a  limb  is  no  proof  of  centric  origin ;  but  if  the  paralysis 
continue  longer  than  a  few  hours  or  a  day  or  two,  especially  if  contraction 
of  muscle  occur,  we  may  conclude  that  some  centric  lesion,  either  primary 
or  secondary,  is  present.  Even  if  unmistakable  evidence  of  a  cerebral  lesion 
is  seen  when  the  convulsion  is  at  an  end,  it  does  not  follow  that  the  lesion 
was  the  cause  of  the  fit.  One  consequence  of  eclamptic  seizures  is  conges- 
tion of  the  brain ;  and  if  the  nervous  attack  be  prolonged,  serous  effusions, 
and  perhaps  minute  capillary  haemorrhages,  may  occur  and  lead  to  alarming 
consequences.  A  case  in  which  death  took  place  from  this  cause  has 
akeady  been  narrated. 


282  DISEASE  IF   CHILDEEN. 

It  has  beeu  said  that  convulsions  taking  place  at  the  end  of  the  exan- 
themata and  other  febrile  diseases  are  commonly  attributed  to  cerebral 
congestion,  although  it  seems  jDrobable  from  the  observations  of  Dr.  Bas- 
tian  that  embolic  plugging  of  minute  cerebral  arteries  takes  a  large  share 
in  their  production.  These  attacks  never  come  on  except  at  an  advanced 
period  of  the  illness,  when  the  state  of  the  patient  is  evidently  very  serious  ; 
and  they  cjuickly  put  an  end  to  his  sufferings.  It  is  right  here  to  mention 
that  a  fit  may  be  the  first  sign  of  secondary  tuberculosis.  Tubercular 
meningitis,  when  it  occurs  in  the  course  of  an  acute  illness,  has  its  own 
early  symptoms  masked  by  those  proper  to  the  primary  disease,  and  only 
reveals  its  presence  by  the  more  violent  phenomena  which  are  character- 
istic of  the  third  stage  of  the  intracranial  lesion.  Appearing  in  this  form 
— as  a  part  of  a  general  formation  of  the  gray  granulation  all  over  the 
body — tubercular  meningitis  is  not  uncommon  in  babies  of  only  a  few 
months  old.  If,  then,  in  a  child  of  any  age  suffering  from  an  acute  in- 
flammatory disease,  such  as  an  attack  of  acute  catarrhal  pneumonia,  con- 
vulsions come  on,  we  should  strongly  suspect  tuberculosis  ;  and  if  the  fit  is 
followed  by  squinting  and  irregularity  of  pupils,  with  or  without  rigidity  of 
joints,  we  can  speak  confidently  of  the  existence  of  tubercular  inflammation 
in  the  skull  cavity. 

In  cases  where  no  serious  cerebral  lesion  is  suspected,  it  is  important  to 
distinguish  an  eclamptic  attack  from  an  epileptic  seizure.  At  the  time  this 
is  impossible,  for  the  state  of  the  patient  requires  all  our  attention,  and  if 
only  to  quiet  the  alarm  of  the  relatives,  it  is  urgent  that  something  should 
be  done.  When,  however,  the  subsidence  of  the  spasms  gives  us  leisure  to 
make  inquiries,  we  should  try  to  discover  some  source  of  irritation  to  which 
the  convulsion  may  be  attributed.  We  should  look  for  signs  of  rickets — 
the  condition  which  esiDccially  predisposes  to  eclamptic  seizures — and  in- 
quire for  any  convulsive  tendency  in  the  family. 

The  age  is  of  importance.  Uj)  to  the  time  of  completion  of  the  first  den- 
tition the  disturbance  is  i^robably  not  epileptic  ;  and  if  the  gums  are  tense 
or  hot,  or  the  child  has  lately  swallowed  some  unsuitable  food,  we  may 
feel  satisfied  that  the  case  is  one  of  pure  eclampsia.  Again,  high  fever  is 
not  a  characteristic  of  epilepsy  ;  therefore,  if  there  be  pj'rexia,  the  fit 
is  probably  reflex,  or  is  a  nervous  distiu-bance  announcing  the  onset 
of  one  of  the  exanthemata  or  of  an  acute  disease.  But  irrespective  of 
these  considerations,  under  the  age  of  two  years  epilepsy  is  rare,  w^hile 
reflex  convulsions  and  the  other  forms  of  pure  eclampsia  are  very  com- 
mon. 

In  older  children  it  is  more  difficult,  often  it  is  quite  impossible,  to  ex- 
clude epilepsy.  If,  however,  the  fit  is  a  prolonged  one,  and  lasts  for  an 
hour  or  more  without  intermission,  we  may  conclude  that  the  attack  is 
eclamptic,  for  the  duration  of  an  epileptic  seizure  rarely  exceeds  ten  min- 
utes, or  at  the  most  a  quarter  of  an  hour.  When  the  urine  can  be  obtained 
it  should  be  always  examined  for  albumen,  as  ursemic  convulsions  in  chil- 
dren are  not  uncommon.  For  the  same  reason  the  whole  body  should  be 
carefully  inspected  for  signs  of  peeling  of  the  skin,  as  ursemic  convulsions 
towards  the  end  of  the  desquamative  stage  of  scarlatina  are  far  from  rare. 
The  attack  of  scarlatina  is  sometimes  so  mild  as  to  be  overlooked  by  inat- 
tentive or  unobservant  parents  ;  and  even  if  it  be  known  to  have  occurred, 
the  past  illness  may  be  looked  upon  as  immaterial  to  the  present  disturb- 
ance, and  may  not  be  referred  to.  In  all  cases  we  must  remember  that 
after  the  age  of  three,  or  at  the  most  four  years,  eclamptic  attacks  from 
reflex  irritation  are  rare.     Convulsions  occurring  in  a  child  of  this  age,  if 


CONVULSIONS — PROGNOSIS.  283 

not  due  to  epilepsy  or  cerebral  disease,  are  generally  either  uraemic  or  are 
premonitory  of  some  acute  febrile  disease. 

As  long  as  any  cause  can  be  discovered  for  the  attack  the  fit  is  prob- 
ably eclamptic.  It  is  the  convulsion  occurring  without  evident  reason 
that  is  so  suspicious  of  true  epilepsy  ;  and  if  a  child  of  four  or  five  years 
old,  or  upwards,  be  visited  while  in  apparent  health  by  such  a  seizure,  we  are 
justified  in  fearing  the  beginning  of  epilepsy.  It  must  be  remembered, 
however,  that  convulsive  seizures,  at  first  eclamptic,  may  pass  into  true 
epilepsy.  There  is  no  doubt  that  this  does  happen  in  cases  where  there  is 
a  strong  neurotic  inheritance.  Where  there  is  no  such  predisposition  I 
believe  that  epilepsy  only  follows  in  cases  where  the  eclamptic  attack  has 
induced  a  secondary  cerebral  lesion.  In  such  a  case,  although  the  first 
attack,  or  series  of  attacks,  may  have  occurred  as  a  result  of  some  apprecia- 
ble cause,  the  after  convulsions  may  arise  without  anything  being  discov- 
ered to  serve  as  an  explanation  of  the  morbid  j)henomenon. 

Prognosis. — Eclampsia  is  a  symptom  which  may  be  serious  or  not  ac- 
cording to  circumstances.  In  estimating  the  importance  of  the  symptom 
we  must  consider  the  age  of  the  child,  the  natpre  and  severity  of  the  at- 
tack, and  the  i^robable  cause  which  has  induced  it.  Infants  of  a  few  weeks 
old  often  die  even  from  purely  reflex  convulsions  if  the  seizures  are  vio- 
lent. Older  children  have  a  better  chance  of  recovery.  After  the  first 
few  weeks  of  life  much  depends  upon  the  cause  of  the  attack.  Purely 
reflex  fits  and  the  initial  convulsions  of  acute  disease  rarely  end  otherwise 
than  favourably.  Again,  the  convulsions  which  arise  from  imperfect  aera- 
tion of  the  blood,  such  as  may  occur  in  pertussis,  are  often  recovered  from ; 
but  when  the  cause  is  collapse  of  the  lung  they  are  generally  fatal.  In 
pertussis,  however,  convulsions  may  be  of  several  kinds,  of  which  some  are 
more  serious  than  others.  Those  due  to  cerebral  congestion  and  throm- 
bosis are  invariably  fatal.  Eclampsia  arising  from  congestion  and  a-nternia 
of  the  brain  are  especially  serious,  because  they  usually  take  place  when 
the  patient  is  already  in  a  state  of  great  exhaustion.  When  convulsions 
occur  towards  the  close  of  the  eruptive  stage  of  measles  or  scarlatina,  they 
must  be  looked  upon  as  a  very  dangerous  symptom.  Ursemic  fits  often 
pass  away  without  producing  serious  consequences.  Whatever  be  the 
cause  of  the  attack,  stertorous  breathing,  great  lividity  of  the  face  with 
blueness  of  the  nails,  or  a  very  rapid  pulse  should  excite  the  gravest  ap- 
prehensions. As  a  rule,  the  prospect  becomes  more  unfavourable  in  pro- 
portion to  the  rapid  succession  of  the  eclamptic  seizures  and  the  severity 
of  the  attacks.  The  occurrence  of  a  large  fiow  of  urine,  according  to  M. 
Simon,  is  a  sign  of  good  omen,  indicating  that  the  convulsive  movements 
are  about  to  cease. 

In  convulsions  from  cerebral  disease  it  need  not  be  said  that  prognosis 
is  most  unfavourable  ;  and  if  the  fits  are  followed  by  stupor,  squinting,  or 
irregularity  and  sluggishness  of  the  pupils,  we  can  have  little  hope  of  the 
patient's  recovery. 

The  influence  which  the  attack  is  likely  to  have  upon  future  brain-de- 
velo]3ment  is  a  point  of  importance,  and  much  anxiety  is  usually  manifested 
on  the  subject  by  the  child's  relatives.  In  the  commonest  case,  that  in 
which  a  rickety  child  has  a  fit  as  a  result  of  some  trifling  irritant,  I  be- 
lieve the  attack  to  be  usually  unimportant ;  and  familiar  as  is  the  experi- 
ence, have  rarely  known  the  patient  to  suffer  from  any  after  ill-conse- 
quences. So  in  the  case  of  the  other  forms  of  purely  reflex  convulsions,  the 
eclamptic  seizure  is  due  to  some  temporary  condition,  or  set  of  conditions, 
which  may  pass  off,  if  the  child  survives,  leaving  the  brain  unharmed.     If, 


284  DISEASE  IN   CHILDEEN. 

however,  the  patient  belong  to  a  family  in  which  nervous  disorders  are  com- 
mon, convulsive  seizures  assume  greater  significance.  If  the  attacks  are 
often  repeated,  the  prospect  as  regards  the  mental  development  of  the  child 
is  unfavourable,  for  such  cases  may  end  in  e]3ilepsy  or  even  idiocy.  In  all 
cases,  too,  where  the  convulsions  are  connected,  either  as  cause  or  effect, 
with  some  intracranial  lesion,  and  where  they  are  followed  by  signs,  more 
than  merely  temporary,  of  muscular  weakness,  there  is  no  doubt  that  for 
the  time  the  brain  is  injured  by  the  illness.  In  cases  of  recovery  especial 
care  would  then  have  to  be  exercised  in  the  child's  education  so  as  not  to 
put  too  great  a  strain  upon  his  faculties. 

Ty-eatment. — When  called  to  a  case  of  convulsions  th6  practitioner 
should  lose  no  time  in  questioning  the  attendants,  but  should  at  once  have 
the  child  placed  in  a  warm  bath  of  the  temperature  of  90°  Fah.,  and  apply 
sponges  dipped  in  cold  water  to  his  head.  This  is  the  time-honoured 
remedy  :  it  is  certainly  an  innocent  one  :  it  may  tend  to  quiet  the  nervous 
system,  and  it  is  one  the  efficacy  of  which  is  so  generally  recognised 
amongst  the  public,  that  it  would  be  unwise  to  coiu-t  unfavourable  criti- 
cism by  neglecting  to  employ  it.  The  bath  must  not  be  continued  too 
long.  In  ordinary  cases  the  child  should  be  allowed  to  remain  in  it  for 
ten  or  twenty  minutes,  according  to  his  age.  If,  however,  the  patient  be 
an  infant  who  has  lately  been  reduced  by  an  exhausting  diarrhoea,  he  should 
not  be  allowed  to  remain  more  than  two  or  three  minutes  in  the  warm 
water,  and  cold  applications  to  the  head  may  be  dispensed  with.  If  the 
convulsions  have  ceased  when  the  case  is  first  seen,  the  bath  need  not  be 
used  ;  but  we  should  not  omit  to  have  the  child  completely  undressed,  and 
then  to  see  that  he  is  placed,  lightly  covered,  in  a  large  cot,  and  that  the 
room  in  which  he  lies  is  weU  ventilated  and  not  too  light.  Care  should 
be  taken  to  unload  the  bowels  by  a  large  enema  of  soap  and  water  ;  and  if 
the  child  be  noticed  to  retch,  his  stomach  may  be  relieved  by  a  teaspoon- 
ful  of  ipecacuanha  wine.  In  the  case  of  a  teething  infant  opinions  dififer 
as  to  the  projDriety  of  lancing  the  gums.  There  is  no  doubt  that  this  op- 
eration is  a  useless  one  if  employed  with  any  hope  of  hastening  the  evolu- 
tion of  the  teeth  ;  but  if  the  object  be  to  reheve  pain  and  tension,  I  con- 
sider the  practice  judicious,  and  never  hesitate  in  such  circumstances  to 
have  recourse  to  it.  If  it  be  desirable  to  remove  all  sources  of  irritation, 
surely  such  a  source  of  irritation  as  a  swollen  and  inflamed  gum  should 
not  be  disregarded.  Lastly,  if  it  can  be  discovered  that  the  child  has  had 
]Dain  in  the  ear,  or  if  the  tympanic  membrane  can  be  seen  to  be  red,  the 
ear  should  be  fomented  with  hot  water  ;  and  if  thought  desirable  a  leech 
may  be  applied  within  the  concha,  the  meatus  being  first  plugged  with 
cotton  wool. 

If  in  spite  of  these  measures  the  convulsions  return,  or  signs  are  no- 
ticed of  continued  irritabihty  of  the  nervous  system,  it  is  best  to  adminis- 
ter a  dose  of  chloral.  Two  grains  can  be  given  to  a  child  between  six  and 
twelve  months  old  ;  and  if  the  patient  be  unable  to  swallow,  half  as  much 
again  may  be  administered  by  the  rectum,  dissolved  in  a  few  teaspoonfuls 
of  water.  If  necessary  the  dose  can  be  repeated  several  times  a  day.  Bro- 
mide of  ammonium,  and  belladonna,  are  also  largely  employed  in  these 
cases.  The  former  may  be  given  in  three  or  four  grain  doses  every  two 
hours  to  a  child  between  six  and  twelve  months  old  ;  the  second  in  ten, 
fifteen,  or  twenty  drop  doses  two  or  three  times  a  day.  In  the  convulsions 
of  pertussis,  where  the  spasm  of  the  glottis  is  extreme,  treatment  by  bro- 
mide of  ammonium  or  potassium  and  belladonna  is  especially  indicated. 
The  bromides  are  well  borne  by  quite  young  childi-en,  and  we  should  not 


CONVULSIONS — TEEATMENT.  285 

fear  ill  consequences  from  what  may  seem  a  very  large  dose.  Chloroform 
also  is  often  employed,  but  is  decidedly  inferior  to  chloral  and  much  more 
troublesome. 

Nitrite  of  amyl  is  a  very  useful  agent  in  arresting  convulsions,  and  may 
be  employed  without  fear  of  danger  even  in  young  infants.  The  remedy 
maj^  be  administered  by  the  mouth  or  by  inhalation.  In  the  case  of  an 
infant  of  six  to  nine  months  old,  one-fourth  of  a  drop  of  the  nitrite  may 
be  given  in  mucilage  and  glycerine  three  or  four  times  a  day  ;  and  if  the 
child  be  actually  convulsed  the  inhalation  of  a  drop  on  a  morsel  of  lint 
will  usually  put  a  speedy  end  to  the  spasmodic  movements.  Even  in  cases 
where  the  convulsive  seizures  are  due  to  cerebral  disease  the  symptom  may 
be  controlled  by  the  same  means.  Dr.  A.  E.  Bridger  has  reported  some 
cases  in  which  this  plan  of  treatment  was  followed  by  the  utmost  benefit 
as  far  as  the  muscular  spasms  were  concerned  ;  for  although  the  nitrite 
cannot  of  course  exercise  any  remedial  influence  upon  the  centric  disease, 
it  is  of  no  small  advantage  to  be  able  to  control  a  symptom  which  of  all 
others  is  distressing  to  those  to  whom  the  patient  is  dear.  Dr.  Bridger 
found  that  it  was  necessary  to  increase  the  dose  every  twenty-four  hours 
by  about  one-third. 

If  the  child  have  been  lately  the  subject  of  exhausting  discharges,  warmth 
should  be  employed,  and  stimulants  such  as  the  brandy-and-egg  mixture  of 
the  British  Pharmacopoeia  must  be  given  energetically. 

If  the  convulsive  attacks  are  followed  by  symptoms  indicative  of  intra- 
cranial mischief,  such  as  stupor,  squinting,  ptosis,  etc.,  the  child  should  be 
kept  quiet  and  an  ice-bag  be  applied  to  his  head.  In  such  cases  the  treat- 
ment must  be  conducted  according  to  the  conditions  from  which  the  con- 
vulsion is  supposed  to  have  arisen. 

When  the  convulsions  have  ceased,  and  signs  of  ii'ritabiHty  of  the  ner- 
vous system  are  no  longer  to  be  observed,  we  must  take  steps  to  improve 
the  general  condition  of  the  patient.  His  bowels  should  be  attended 
to,  and  his  diet  carefully  regulated.  If  rickets  be  present,  it  must  be 
treated  according  to  the  directions  laid  down  for  the  management  of  these 
cases.  Most  children  in  whom  the  convulsive  tendency  exists  are  benefited 
by  iron  wine  and  cod-Hver  oil,  for  their  nutrition  is  usually  at  fault,  and 
both  the  alcohol  and  the  iron  contained  in  the  wine  are  beneficial,  while 
the  oil  is  of  the  utmost  value  in  supplying  nutritive  deficiencies.  Fresh 
air,  too,  is  of  extreme  importance,  and  the  child  should  be  warmly  dressed 
and  taken  regularly  out  of  doors. 


CHAPTER  Y. 

EPILEPSY. 

Epilepsy,  a  disease  wHch  may  vary  in  severity  from  the  most  transient  un- 
consciousness to  violent  convulsions  and  profound  coma,  is  not  uncommon 
in  children.  It  has  been  estimated  that  nearly  one-third  of  the  cases  met 
■with  in  the  adult  have  begun  under  the  age  of  ten  years.  The  malady  is 
one  of  pecuhar  importance  in  early  life,  on  account  of  its  tendency  to  influ- 
ence injuriously  the  development  of  the  brain. 

Causation. — In  a  large  proportion  of  cases  of  epilepsy  there  is  a  hered- 
itary neurotic  tendency.  We  often  find  a  family  history  of  epilepsy,  of 
insanity,  or  of  some  form  of  nervous  derangement.  If  this  is  the  case  on 
the  side  of  both  parents  the  child's  prospect  is  a  sad  one,  and  in  such 
families  every  cloild  may  be  afflicted  with  some  form  of  neurotic  distiu'b- 
ance.  Habitual  intemperance  in  alcohol  on-  the  part  of  the  father  or 
mother  is  said  to  have  a  determining  influence  in  the  causation  of  epilepsy 
in  the  child.  Lancereaux  insists  upon  the  importance  of  this  cause,  and 
states  that  a  tendency  to  convulsions  in  their  offspring  is  a  common  con- 
sequence of  alcoholism  in  the  jparents. 

Cachectic  conditions  resulting  from  imperfect  nutrition  or  disease,  such 
as  anaemia,  chlorosis,  and  scrofula,  have  been  said  to  favoui-  the  develop- 
ment of  epilepsy  ;  but  I  can  find  no  sufficient  foundation  for  this  statement. 
Rickets  contributes  largely  to  the  occurrence  of  eclamptic  attacks  in  in- 
fancy, but  it  does  not,  according  to  my  experience,  especially  predispose 
to  epilepsy  unless  there  be  strong  hereditary  neurotic  tendency  ;  for  when 
the  disease  passes  oft",  as  it  will  do  readily  if  the  causes  exciting  it  be  re- 
moved, the  proneness  to  conviilsive  seizures  also  subsides. 

Amongst  the  exciting  causes  of  epilepsy  violent  emotions,  such  as  terror 
and  fright,  take  a  prominent  place.  Injuries,  such  as  blows  or  falls  xipon 
the  head,  are  answerable  for  many  of  the  cases.  It  is  also  common  to  find 
the  paroxysms  attributed  in  the  first  place  to  eclamptic  attacks  occurring 
dui'ing  childhood.  It  seems  probable  that  in  many  cases  of  infantile  con- 
vulsions some  change  takes  place  in  the  brain  during  the  course  of  the  fit, 
which  afterwards  induces  a  return  of  the  seizures  without  discoverable 
cause. 

A  bright,  healthy  little  boy,  aged  eleven  months,  in  whose  family  I 
could  discover  no  neurotic  history  with  the  exception  that  his  father  and 
one  of  his  uncles  had  had  fits  in  infancy,  was  taken  ill  on  August  31,  1870. 
Some  pustules  appeared  on  his  legs  and  he  was  feverish.  On  the  next 
morning  he  was  seized  with  a  convulsive  fit  which  lasted  with  occasional 
intermissione  for  several  hours  and  left  him  paralysed  on  the  right  side. 
During  the  ne:xt  three  days  he  remained  in  a  drowsy  state  and  was  feverish 
at  night.  I  saw  him  for  the  first  time  on  September  4th.  The  child,  a 
healthy-looking  boy,  had  but  three  teeth.  Still,  although  backward  in  this 
respect'  for  his  age,  he  showed  no  other  sign  of  rickets.    He  was  lying  with 


EPILEPSY — CAUSATION — PATHOLOGY.  287 

closed  eyes  on  his  mother's  lap.  His  pupils  were  equal  and  acted  well 
with  light ;  his  pulse  146,  was  regular  in  rhythm  but  not  in  force  ;  his 
breathing  was  irregular  and  interspersed  with  sighs,  although  without 
long  pauses  ;  the  temperature  in  the  rectum  was  101.6°.  Both  legs  were 
covered  from  the  knee  to  the  ankle  with  an  erysipelatous  blush.  Power 
over  them  was,  however,  being  restored,  for  the  child  moved  the  right 
arm  readily  and  the  leg  a  little.  At  first  they  had  been  completely 
paralysed.  His  lungs  and  heart  were  healthy.  The  child  seemed  stupid 
but  was  not  unconscious,  for  he  watched  a  light  passed  before  his  eyes, 
and  during  examination  of  his  chest  cried  and  twisted  himself  about. 
When  the  teat  of  his  feeding-bottle  was  given  to  him,  he  seized  it  eagerly 
and  put  it  into  his  mouth.     There  was  no  paralysis  of  the  face. 

The  convulsions  in  this  case  had  been  evidently  an  initial  symptom  of 
the  erysipelatous  inflammation,  and  must  have  led  to  a  small  extravasation 
or  other  structural  lesion  in  the  brain  ;  for  although  the  child  quickly  re- 
covered the  use  of  his  limbs,  he  became  subject  from  that  time  to  frequent 
slight  fits,  which  were  no  doubt  of  an  epileptic  nature.  They  came  on 
every  two  or  three  weeks  without  discoverable  cause  and  lasted  for  one  or 
two  minutes.  The  boy  was  said  to  become  suddenly  very  quiet ;  then,  in 
a  moment,  his  cheeks  flushed,  his  lips  became  purple,  his  eyes,  although 
not  exactly  fixed,  had  an  unnatural  look,  and  he  lost  consciousness  com- 
j)letely.  He  did  not  twitch.  When  the  fit  came  on  he  never  fell,  for  his 
nurse  seeing  his  sudden  quiet  and  anticipating  what  was  to  follow  always 
took  him  up  in  her  arms.  In  spite  of  treatment  these  attacks  became  con- 
firmed, and  in  1882 — ^the  boy  being  then  twelve  years  of  age — were  still 
going  on.  Occasionally  he  had  a  more  perfect  seizure,  but  usually  the  at- 
tacks were  of  the  character  which  has  been  described. 

The  above  illustration  I  believe  to  be  typical  of  a  class,  and  am  strongly 
of  opinion  that  the  origin  of  many  cases  of  ej)ilepsy  in  the  child  can  be  re- 
ferred to  a  similar  accident.  In  other  cases  where  there  is  a  strong 
neurotic  predisposition,  and  the  gray  matter  of  the  brain  is  in  a  highly 
explosive  state,  it  is  possible  that  eclamptic  attacks  originally  induced  by 
some  trifling  irritant  may  become  perpetuated  as  epileptic  seizures  without 
discoverable  cause.  Where  no  such  predisposition  exists,  and  no  lesion  is 
present  in  the  brain,  I  know  of  no  proof  that  convulsive  seizures  can  be  so 
perpetuated. 

Pathology. — No  anatomical  characters  have  been  discovered  by  which 
the  occurrence  of  epileptic  attacks  can  be  explained,  and  hence  the  nature 
of  the  disease  is  still  a  matter  of  speculation  and  doubt.  The  seizures 
have  been  attributed  to  both  anaemia  and  congestion  of  the  brain,  the 
seat  of  the  faulty  action  has  been  referred  to  the  medulla  oblongata  and 
the  upper  ]3art  of  the  spinal  cord,  to  the  ganglia  at  the  base  of  the  brain, 
and  to  the  cerebral  convolutions.  We  have  learned  by  expei-iment  that 
lesions  of  the  convolutions  will  induce  muscular  spasm,  and  that  irritation 
of  the  cortex  in  the  motor  region  will  have  the  same  effect.  Nothnagel, 
too,  has  pointed  out  on  the  floor  of  the  fourth  ventricle  a  limited  area, 
which  he  calls  the  "  convulsion  centre,"  on  irritation  of  which  all  the 
voluntary  muscles  of  the  body  are  thrown  into  tonic  and  clonic  spasms. 
Any  or  all  of  these  parts  may  then  be  concerned  in  the  production  of  an 
epileptic  seizure.  It  can  hardly  be  doubted  that  sometimes  the  convolu- 
tions may  be  the  seat  of  the  nervous  discharge,  for  in  a  certain  proportion 
of  cases  where  at  the  beginning  of  the  fit  the  patient  is  conscious  of  his 
condition,  the  discharge  occurs  in  a  centre  of  special  sense  ;  also  in  cases 
where  the  aura  is  intellectual  the   hemispheres   are   probably   at  fault. 


288  DISEASE   I]Sr   CHILDEEX. 

"When  the  attack  is  distinctly  reflex,  tlie  mediilla  oblongata  and  pons  may- 
contain  the  seat  of  diseased  action  ;  and  the  fact  that  in  all  cases  there  is 
more  violence  of  spasm  on  one  side  of  the  body  than  on  the  other  seems 
to  point  to  some  controlling  influence  of  the  corpus  striatum. 

The  loss  of  consciousness  has  been  explained  to  be  the  consequence  of 
anaemia  due  to  spasm  of  the  cerebral  arteries  and  capillaries,  and  caused 
by  an  extension  of  the  discharge  to  the  vaso-motor  centre.  According  to 
another  theory,  consciousness  is  arrested  as  the  result  of  an  influence 
"which  radiates  from  the  part  affected  to  the  sensorium.  The  after-symp- 
toms have  been  ascribed  to  carbonic  acid  poisoning  from  partial  asphyxia, 
and  this  ^\-as  long  held  to  be  a  sujB&cient  explanation,  although  lately  doubts 
have  been  expressed  as  to  its  correctness.  At  jDresent,  however,  no  ex- 
planation has  passed  out  of  the  region  of  hypothesis,  and  although  dif- 
ferent theories  may  have  different  degrees  of  plausibihty,  none  can  be  said 
to  rest  upon  any  very  sohd  foundation. 

Symjytoms.—The  sjTnptoms  of  epilepsy  are  very  various.  Although 
the  con\iilsive  movements  are  the  part  of  the  seizure  which  most  forcibly 
attracts  the  attention,  they  are  not  essential  to  the  nature  of  the  disorder. 
The  most  characteristic  feature  is  the  loss  of  consciousness,  and  this,  al- 
though often  transient,  is  very  rarely  completely  absent.  A  severe  fit  of 
epilepsy  is  much  the  same  in  the  child  that  it  is  in  the  adult,  and  it  will  be 
unnecessary  to  describe  minutely  the  characters  of  a  seizure  with  which 
everyone  must  be  familiar.  The  main  features  of  the  attack  are  similar  to 
those  akeady  described  as  characteristic  of  eclamjDsia.  It  is  preceded  by 
a  prodromal  period  of  variable  duration,  in  which  some  change  is  noted  in 
the  character,  manner,  or  expression  of  the  patient.  The  convulsion  it- 
self seldom  lasts  longer  than  a  few  minutes.  It  is  followed  by  a  stage  of 
coma,  which  is  usually  more  protracted,  but  sooner  or  later  the  child  re- 
covers consciousness,  although  he  may  remain  more  or  less  stupid  for 
some  hours.  Often  recovery  is  marked  by  a  profuse  discharge  of  hmpid 
urine.  In  many  cases  the  onset  of  the  fit  is  announced  in  the  child,  as  it 
is  in  the  adult,  by  an  "  aura."  In  others  the  first  symptom  is  vertigo,  or  a 
sudden  flushing  or  pallor,  or  a  twitching  of  some  particular  muscle.  "What- 
ever this  initial  symptom  may  be,  it  is  usually  rej)eated  before  each 
attack. 

The  more  severe  seizures  (epilepsia  gravior  or  haut  mal)  seldom  appear 
in  aU  their  gravity  when  the  child  first  becomes  subject  to  the  disease. 
They  are  usuaUy  preceded  for  months  or  years  by  a  milder  form  of  the 
affliction  (epilepsia  mitior,  petit  mal,  or  epileptic  vertigo)  which  presents 
itself  in  very  many  different  forms. 

In  all  varieties  of  epUeptic  vertigo,  loss  or  clouding  of  the  conscious- 
ness, which  may  be  momentary,  is  the  main  featiu'e,  and  is  sometimes  the 
only  symptom.  Thus,  a  child  while  engaged  at  his  lessons  or  his  play  stops 
all  at  once  in  what  he  is  doing  and  rests  for  a  time  perfectly  quiet  with 
dUated  pupils  and  a  strange  fixed  gaze  ;  then  after  a  few  seconds  he  re- 
cover himself  and  continues  his  occupation.  Instead  of  being  perfectly 
still,  he  may  mutter  some  incoherent  words  or  may  perform  some  curious 
or  unexpected  act.  Sometimes  his  face  may  lose  its  colour,  or  a  twitch- 
ing may  be  noticed  in  one  cheek,  lij),  or  eyelid,  or  his  head  may  be  drawn 
to  one  side.  In  any  case,  when  consciousness  returns  the  child  is  quite 
ignorant  of  what  has  passed,  and  immediately  continues  the  action  in 
which  he  was  engaged.  In  other  instances  he  merely  seems  for  the  time 
to  be. puzzled  and  confused,  and  does  not  recognise  his  friends.  In  other 
cases,  again,  an  ordinary  peaceful  and  affectionate  boy  will  suddenly  do 


EPILEPSY— SYMPTOMS.  289 

some  savage  or  spiteful  act  which  is  strangely  foreign  to  his  real  disposi- 
tion, and  which  afterwards  he  is  quite  ignorant  of  having  perpetrated. 

A  little  boy,  aged  twelve  years,  well  nourished  and  healthy  looking, 
had  always  been  well  until  September,  1877,  when  he  had  an  attack  of 
pertussis.  During  this  time  he  noticed  that  objects  "looked  small"  to 
him  for  a  moment.  On  recovery  from  the  whooping-cough  he  returned 
to  his  day-school,  and  one  evening,  when  doing  his  lessons,  he  seemed 
all  at  once  to  be  "puzzled  and  confused,  and  did  not  know  his  father." 
Since  then  he  had  had  some  well-marked  epileptic  fits. 

The  boy  was  brought  to  me  in  May,  1878.  He  then  complained  of 
slight  but  constant  shooting  pain  in  his  right  temple.  I  was  told  that  he 
seldom  had  a  genuine  epileptic  fit,  but  that  he  was  very  subject  to  attacks 
of  mental  aberration  in  which  he  did  strangely  spiteful  things.  The  at- 
tacks were  said  to  last  from  a  few  seconds  to  ten  minutes  and  to  end  in  a 
stupor  of  about  a  minute's  duration.  On  recovery  he  was  always  quite 
ignorant  that  anything  extraordinary  had  occurred.  While  standing  be- 
fore me  the  boy  had  an  epileptic  seizure.  He  turned  his  face  away  over 
his  left  shoulder,  remained  for  about  thirty  seconds  perfectly  motionless, 
and  then  fell  backwards  into  his  mother's  arms.  His  face  continued  per- 
fectly placid  and  did  not  change  colour.  The  eyes  were  closed,  and  when 
the  lid  was  raised  were  seen  to  be  turned  upwards  and  to  the  right. 
There  was  a  faint  twitch  noticed  twice  in  the  fingers  of  the  right  hand. 
The  pulse  was  full  and  regular.  After  being  in  his  mother's  arms  for 
about  sixty  seconds,  he  suddenly  changed  his  position ;  and  then  in 
another  minute  sat  up,  looked  about  him,  and  seemed  quite  recovered. 

Attacks  of  epileptic  vertigo  may  come  on  suddenly,  or  may  be  preceded 
by  certain  premonitory  warnings,  which  soon  come  to  be  recognised  by 
the  friends  as  hkely  to  be  followed  by  a  seizure.  The  warning  may  be 
a  headache,  a  pain  in  the  body  or  a  limb,  an  attack  of  sickness,  the  con- 
traction or  spasm  of  a  muscle,  or  some  curious  change  in  the  habits  or 
disposition  of  the  patient.  It  may  precede  the  attack  by  several  houi-s  or 
a  day  or  two.  Sometimes  it  occurs  without  being  followed  by  a  fit.  Epi- 
leptic vertigo  often  in  time  develops  into  the  more  pronounced  form  of 
the  disease.  Usually,  as  in  the  case  above  narrated,  rare  attacks  of  gen- 
uine epilepsy  are  separated  by  long  intervals,  during  which  the  patient  is 
afflicted  by  repeated  seizures  of  the  disease  in  a  milder  form.  Often  the 
severer  fits  occur  only  at  night  and  may  be  thus  overlooked  for  a  time. 
Epileptic  vertigo  always  recurs  much  more  frequently  than  the  genuine 
epileptic  seizures,  and  the  patient  may  suffer  from  many  such  attacks  in 
the  course  of  a  single  day. 

Between  the  attacks,  whether  of  the  graver  or  lighter  form  of  the  dis- 
ease, the  child  may  seem  perfectly  weU  both  in  mind  and  body.  He  may 
be  animated,  intelligent,  active,  and  seem  in  no  way  harmed  by  his  afflic- 
tion. In  other  cases,  especially  if  the  attacks  have  dated  from  infancy, 
there  is  manifest  interference  with  mental  development,  and  the  child 
may  either  have  the  manner  and  intelligence  of  one  much  yoimger  than 
his  age,  or  be  dull  and  stupid  even  to  idiocy.  In  the  case  already  referred 
to — the  little  boy  in  whom  the  attacks  began  at  the  age  of  eleven  months 
— when  four  years  old  he  was  intellectually  on  a  level  with  a  child  of  half 
his  years.  He  sat  on  the  floor  and  played  with  his  toys  with  the  manner 
of  a  baby,  and  had  only  learned  to  feed  himself  during  the  previous  six 
months.  Although  he  understood  all  that  was  said  to  him,  he  could  only 
say  a  few  words,  and  could  not  pronounce  the  lettei's  s,  1,  n,  or  m.  At  the 
age  of  five  years  he  began  to  have  daily  lessons  from  a  governess,  who  re- 
19 


290  DISEASE   IN   CHILDEEN. 

ported  him  as  "  not  difficult  to  teacli."  At  twelve  years  of  age  the  fits  still 
continued,  although  they  were,  as  a  rule,  mild  and  infrequent,  and  oc- 
curred at  intervals  of  six  weeks,  two  months,  or  longer.  His  father  stated 
at  this  time,  in  answer  to  a  letter  making  inquiry  as  to  the  boy's  progress, 
that  his  mental  power  was  below  the  average,  and  that  the  lad  was  far 
behind  other  boys  of  his  age. 

The  severe  convulsions  which  occur  at  comparatively  long  intervals 
seem  to  have  a  less  disastrous  influence  upon  mental  development  than  the 
milder  epileptiform  seizures  which  occur  more  frequently.  Also,  as  has 
been  before  remarked,  the  age  at  which  the  seizures  begin  is  a  very  impor- 
tant matter.  If  the  child  has  been  subject  to  them  from  before  the  com- 
pletion of  the  first  year  of  life,  his  mental  development  is  almost  certain  to 
be  injuriously  affected. 

Sometimes  choreic  movements  occur  in  epileptic  children,  for  there 
appears  to  be  an  association  between  the  two  diseases.  A  choreic  child 
may  develop  epilepsy;  and  a  child  subject  to  epileptic  fits  may  become 
choreic.  Dr.  Gowers  has  published  some  interesting  cases  illustrating  this 
connection. 

Diagnosis. — An  eclamptic  attack  in  infancy  and  early  childhood  pre- 
sents exactly  the  same  characters  as  a  fit  of  genuine  epilepsy,  therefore  it 
is  very  important  to  decide  in  every  instance  to  which  class  of  convulsive 
disease  the  attack  is  to  be  referred.  This  question  has  already  been  dis- 
cussed elsewhere  (see  page  282). 

Epileptic  vertigo,  when  it  takes  the  form  of  loss  of  consciousness  with- 
out muscular  spasm,  is  liable  to  be  mistaken  for  an  attack  of  syncope, 
esiDecially  in  those  cases  where  there  is  gi'eat  pallor  of  the  face.  The 
seizures,  indeed,  are  constantly  spoken  of  by  the  parents  as  fainting  fits, 
and  we  must  be  on  our  guard  against  this  interpretation  of  the  phenome- 
non. But  sjTicope,  although  not  uncommon  in  young  people,  is  seldom 
seen  except  as  a  consequence  of  weakness,  prolonged  and  exhausting  dis- 
ease, or  flatulent  accumulation  occurring  in  an  anaemic  child.  Epileptic 
children  are  often  robust  and  generally  appear  to  be  well  nourished. 
Again,  sHglit  twitching  of  muscle,  combined  with  complete  loss  of  con- 
sciousness, would  point  to  epilepsy.  In  syncope  there  are  no  twitchings, 
and  if  any  muscular  movement  occur  insensibihty  is  not  complete. 
Lastly,  an  epileptic  attack  is  sudden,  and  when  the  child  recovers  he  is 
ignorant  of  what  has  passed  ;  syncope  is  preceded  by  a  very  distinct  sense 
of  "  faintness,"  and  after  the  attack  is  at  an  end  the  patient  is  quite  aware 
that  he  has  been  unconscious. 

Cases  of  cerebral  disease  with  partial  convulsions  may  be  mistaken  for 
this  disorder,  but  in  such  cases  there  is  a  history  diiTering  widely  from 
that  of  epilepsy,  and  other  symptoms  of  cerebral  disease  are  present.  Be- 
sides, in  the  attack  we  do  not  find  the  pecuHar  interference  with  respiration 
which  is  so  characteristic  of  an  epileptic  seizure. 

Even  in  the  case  of  children  it  is  necessary  to  be  on  our  guard  against 
the  hysterical  simulation  of  epileptic  seizures  both  on  the  part  of  boys  and 
girls.  These  false  attacks  can  be  usually  recognized  without  difficulty.  A 
boy,  eleven  years  of  age,  was  admitted  into  the  East  London  Children's 
Hospital  under  the  care  of  my  colleague.  Dr.  Donkin,  with  a  history  of  fits 
which  were  supposed  to  be  epileptic.  There  was  no  neurotic  tendency  in 
the  family,  and  the  patient  had  always  been  healthy  until  the  beginning  of 
July,  when  he  was  noticed  to  look  pale.  He  was  said  to  have  been  exposed 
shortly  before  to  a  hot  sun,  and  also  to  have  received  a  heavy  blow  on  the 
head  of  which  for  some  time  he  seemed  to  feel  the  effects.     On  July  13th 


EPILEPSY — DIAGNOSIS — TREATMENT.  291 

he  had  a  fit  in  the  night,  which  was  supposed  to  be  a  faint.  During  the 
next  fortnight  he  suffered  frequently  from  the  attacks,  often  passing- 
through  as  many  as  eight  or  nine  in  the  day.  The  description  given  was 
that  he  felt  giddy,  fancied  he  saw  "things  going  round  him,"  made  a  clutch 
at  some  imaginary  object,  and  then  with  a  cry  fell  backwards.  He  was  said 
to  foam  at  the  mouth,  but  not  to  bite  his  tongue  although  he  clenched  his 
teeth  firmly  ;  to  make  convulsive  movements  with  his  arms  as  if  fighting  ; 
and  sometimes  to  lie  motionless  with  closed  eyes.  The  mother  thought  he 
lost  consciousness.  The  fit  sometimes  lasted  half  an  hour.  It  was  not  fol- 
lowed by  stupor,  but  the  boy  remained  for  some  time  oppressed  and  weary, 
and  stammered  when  he  attempted  to  talk. 

The  first  day  he  passed  in  the  hospital  he  had  eight  attacks.  In  these 
he  struck  out  with  his  arms,  dashing  his  hands  against  the  bars  of  his  bed, 
but  always  striking  with  the-  fleshy  part  of  the  fist,  never  with  the  knuckles. 
He  also  kicked  out  with  his  feet  as  if  keeping  off  some  enemy.  He  threw 
back  his  head,  and  his  face  was  much  flushed  by  his  exertions.  It  never 
became  blue,  nor  was  there  any  arrest  of  respirations.  The  eyelids  were 
closed  and  he  resisted  opening  them.  When  the  conjunctiva  was  touched 
he  winked.  The  pupils  were  not  dilated.  He  did  not  injure  his  tongue 
even  if  he  caught  it  between  his  teeth,  and  all  his  movements  had  a  cer- 
tain voluntary  character.  There  was  no  stage  of  tonic  contraction.  After 
the  fit  was  over  he  lay  down  with  closed  eyes  as  if  to  sleep. 

On  the  second  day  a  sharp  galvanic  current  was  applied  to  the  boy's 
spine.     After  this  experience  he  had  no  more  attacks  of  convulsion. 

Epileptic  fits  which  occur  in  the  night  only  are  often  overlooked.  In 
such  cases  the  fact  that  a  child  suddenly  begins  to  wet  his  bed  at  night  is 
suspicious,  and  if  a  neurotic  tendency  exist  in  the  family,  the  symptom 
should  lead  us  to  make  further  inquiries. 

Prognosis. — Cases  where  the  attacks  are  well  developed  and  occur  infre- 
quently are  more  hopeful  than  the  modified  seizures  which  continually  re- 
turn. Certainly  they  are  more  amenable  to  treatment.  The  age  at  which 
the  affliction  first  manifests  itself  has  less  influence  on  the  curabiHty  of  the 
■disorder  than  it  is  said  to  have  at  a  later  j)eriod  of  life.  On  account  of 
the  difficulty  in  following  out  these  cases  (for  if  no  immediate  improve- 
ment is  noticed  the  patient  is  very  apt  to  be  lost  sight  of),  my  experience 
in  this  matter  is  too  limited  to  enable  me  to  speak  positively  ;  but  I  am  in- 
clined to  believe  that  the  appearance  of  the  disease  during  the  first  two 
years  of  hfe  is  of  less  favoui'able  import  than  when  it  begins  later.  There 
is  no  doubt  that  at  this  age  its  influence  upon  the  mental  development  of 
the  patient  is  more  hurtful,  especially  as  such  early  appearance  implies  in 
many  cases  a  strong  neurotic  predisposition. 

The  earlier  treatment  is  begtm  after  the  onset  of  the  disease  the  more 
favourable  is  the  prognosis  ;  for  while  the  affliction  is  still  recent,  we  may 
have  hopes  of  putting  an  end  to  the  attacks.  In  confirmed  cases,  espe- 
cially if  there  is  strong  hereditary  tendency,  the  child's  prospect  is  but  a 
gloomy  one. 

Treatment. — It  is  so  seldom  possible  to  discover  and  remove  the  cause 
of  epileptic  seizures  that  little  hope  of  curing  the  patient  by  this  means  can 
be  entertained.  It  is  not,  however,  the  less  desirable  to  reUeve  the  chUd 
of  aU  irritants,  and  to  shield  him  from  all  influences  which  experience  has 
shown  to  be  injurious.  Worms  should  be  inquired  for  ;  the  state  of  the 
bowels  should  be  regulated  ;  evil  habits,  if  indulged  in,  should  be  con- 
trolled ;  and  the  child's  whole  mode  of  life  should  be  arranged  according 
to  the  laws  of  health.     All  sources  of  excitement,  whether  in  games,  cliil- 


292  DISEASE  IN   CHILDEEN. 

drens'  parties,  or  public  amusements,  should  be  strictly  forbidden  ;  and 
although  monotony  of  life  is  to  be  carefully  avoided,  pastimes  which  dO' 
not  over-excite  the  brain  are  to  be  preferred.  The  influence  of  quiet  and 
of  healthy  recreation  uj)on  the  disease  is  ofteji  seen  in  hospital  patients, 
A  child  "who  has  been  admitted  vs^ith  a  history  of  severe  epileptic  seizures, 
occurring  daily  for  months,  may  pass  several  weeks  in  the  wards  and  be 
eventually  dismissed  without  any  symptom  of  his  disease  having  been 
detected.  Careful  gymnastic  exercise  is  of  value  in  promoting  healthy 
change  of  tissue,  but  care  should  be  taken  to  stop  short  of  actual  fatigue. 
With  the  same  object  pursuits  which  occupy  the  mind  while  they  give 
employment  to  the  hands  should  be  encouraged,  such  as  gardening  and 
carpentering.  A  useful  plan  is  to  send  the  child,  under  proper  supervision, 
to  a  farm-house,  where  the  tending  and  feeding  of  animals,  and  all  the  pur- 
suits incidental  to  healthy  country  life,  will  be  found  of  infinite  service  to 
him.  At  the  same  time  the  patient  should  be  kept  under  strict  control ; 
any  taste  he  may  have  for  music,  drawing,  etc.,  should  be  cultivated ;  and 
without  fatiguing  the  mind  by  mental  labour,  much  valuable  instructioiL 
may  be  conveyed  by  conversation  and  the  reading  to  him  of  suitable 
books.  Dr.  West  recommends  simple  chants,  such  as  are  easily  acquired, 
as  a  useful  means  of  improving  imperfect  articulation,  and  suggests  drill- 
ing to  the  accompaniment  of  music  as  valuable  in  correcting  slovenliness 
of  gait  and  aiding  the  child  to  regiilate  voluntary  movement. 

The  question  of  food  is  a  very  important  one,  as  the  frequency  of  recur- 
rence of  the  attacks  may  be  determined  to  some  extent  by  the  judgment 
with  which  his  diet  is  selected.  It  is  a  generally  recognised  fact  that  an 
abundant  meat  diet  is  injurious  to  epileptics,  for  the  brain-tissue  which  it 
helps  to  build  up  is  of  a  more  highly  irritable  composition  than  if  a  less- 
stimulating  dietary  were  enjoined.  Butcher's  meat  must  be  taken  spar- 
ingly, and  the  food  should  consist  principally  of  milk,  vegetables,  poultry^ 
game,  and  white  fish. 

The  drugs  which  I  have  found  the  most  useful  and  which  I  believe  ta 
have  a  decided  influence  in  checking  the  number  and  diminishing  the  se- 
verity of  the  attacks  are  strychnia,  belladonna,  and  the  bromides  ^  of  ammo- 
nium and  potassium.  For  a  child  five  years  of  age  I  begin  with  two  drops 
of  liq.  strychniae  (P.  B.)  and  twenty  drops  of  tinct.  belladonnse  twice  a  day, 
and  give  at  night  half  a  drachm  of  bromide  of  potassium  with  camphor- 
water  sweetened  with  simple  syrup.  This  treatment  should  be  continued 
for  months  together,  increasing  the  dose  of  the  stryclmia  solution  by  one 
drop  and  of  the  belladonna  tinctiu-e  by  three  drops  every  two  weeks.  In 
this  way  large  doses  of  the  drugs  may  be  administered  without  danger.  A 
little  boy,  four  years  of  age,  under  my  care  took  for  a  long  time  seventeen 
drops  of  the  strychnia  solution  (or  about  one-seventh  of  a  grain  of  the  al- 
kaloid) twice  a  day  with  great  benefit.  Another  child — a  little  girl  nine 
years  of  age — by  gradual  addition  to  the  strength  of  her  medicine,  reached 
one-fourth  of  a  grain  of  strychnia  twice  in  the  day.  An  important  part 
of  the  treatment  consists  in  the  administration  of  a  weekly  or  bi-weekly 
aperient,  for  it  is  essential  that  the  bowels  be  regularly  relieved.  Accu- 
mulation of  fsecal  matter  is  a  powerful  excitant  of  con\ailsive  seizures  in  a 
child  of  epileptic  tendencies.     Moreover,  the  continued  use  of  the  bromide 


^  In  all  cases  where  the  bromide  salts  are  being  taken,  however  small  the  dose,  the 
practitioner  must  be  prepared  for  the  occurrence  of  the  bromide  rash.  Some  children 
have  a  curious  sensitiveness  to  these  salts.  A  few  small  doses  of  bromide  of  potassium 
will  produce  in  such  subjects  an  abundant  eruption  which,  if  their  idiosyncrasy  is  not 
recognised,  may  excite  considerable  perplexity. 


EPILEPSY — TEEATMENT.  293 

salts  tends  in  many  children  to  produce  constipation  whicli  may  assume  an 
obstinate  cliaracter.  In  such  cases  it  is  useful  to  combine  the  strychnia 
mixtiu'e  with  one  or  two  drachms  of  infusion  of  senna,  so  as  to  maintain  a 
continued  gentle  action  upon  the  bowels.  The  addition  of  chloral  to  the 
bromide  is  said  to  increase  the  efficacy  of  this  treatment,  and  it  has  been 
stated  that  used  in  this  combination  a  smaller  proportion  of  the  bromide 
is  required  to  produce  an  equal  effect. 

Besides  the  above  remedies,  other  drugs  have  been  employed  in  the 
treatment  of  this  disease,  such  as  the  bromide  and  other  salts  of  arsenic  ; 
the  sulphate,  bromide,  and  oxide  of  zinc  ;  the  oxide  and  nitrate  of  silver  ; 
and  ergot  of  rye.  Very  good  results  are  sometimes  obtained  from  the  use 
of  borax.  This  salt  may  be  given  in  doses  of  one  grain  for  each  year  of 
the  child's  life.  Borax  is  best  administered  directly  after  food,  for  if  given 
on  an  empty  stomach  it  may  excite  vomiting.  There  is  One  disadvantage 
connected  with  the  use  of  the  remedy.  In  certain  subjects  the  drug  has  a 
tendency  to  cause  psoriasis  which  may  pi'ove  obstinate.  • 

The  attack  may  be  sometimes  arrested  by  the  inhalation  of  chloroform. 
Any  sudden  shock  is  occasionally  useful  to  attain  the  same  object,  such  as 
applying  ammonia  to  the  nose  or  pouring  cold  water  upon  the  head.  Dr. 
Creighton  Browne  advocates  the  inhalation  of  nitrite  of  amyl. 


CHAPTEE  YI. 

MEGRIM. 

Megrim,  or  migraine,  is  a  functional  nervous  disorder  ■wliicli  gives  rise 
to  severe  headache  and  other  nervous  phenomena,  and  often  to  nausea 
and  bilious  vomiting.  The  derangement  is  a  not  uncommon  one  in  child- 
hood, specially  amongst  growing  boys.  Treatment  is  of  peculiar  impor- 
tance at  this  age,  for  if  the  complaint  be  allowed  to  continue  and  the 
attacks  become  frequent,  the  patient  may  be  almost  entirely  incapacitated 
from  pm^suing  his  studies,  and  his  education  may  sufi'er  greatly  in  con- 
sequence. 

Causation. — In  many  cases  megrim  appears  to  be  hereditary.  We  often 
find  on  inquiry  that  one  or  the  other  parent  suffers  or  has  suffered  from 
the  derangement,  or  that  there  is  a  tendency  in  the  family  to  some  form 
of  nervous  disease.  Sometimes,  however,  this  is  not  the  case.  The  dis- 
order then  appears  to  be  acquired.  In  excitable  children  it  may  be  in- 
duced by  continued  mental  effort  in  crowded,  ill-ventilated  school-rooms, 
and  the  common  practice  of  pressing  forward  the  education  at  a  very  early 
age  no  doubt  helps  to  engender  the  disposition  to  suffer  from  this  com- 
plaint. 

Ansemia  and  debihty,  from  which  children  often  sviffer  soon  after  the 
second  crop  of  teeth  begin  to  make  their  appearance,  probably  also  aid  in 
the  production  of  megrim,  and  an  exhausting  illness,  such  as  typhoid  fever, 
sometimes  seems  to  predispose  towards  it.  One  of  the  most  powerful  of 
the  exciting  causes  appears  to  be  confinement  in-doors  combined  with  over- 
feeding in  a  weakly  child.  The  complaint  is  much  more  common  amongst 
the  children  of  well-to-do  parents  than  amongst  the  children  of  the  poor, 
who  pass  so  much  of  their  time  playing  in  the  streets. 

Megrim  is  not  seen  in  early  childhood.  It  rarely  begins  to  show  itself 
before  the  beginning  of  the  second  dentition,  at  about  the  sixth  year.  I 
have,  however,  kno-^Ti  it  to  occur  in  a  little  boy  five  years  old. 

Pathology. — The  view  formerly  held  that  the  head  symptoms  were  the 
consequence  of  gastric  distm-bance  is  now  practically  abandoned.  Dr. 
Latham  refers  the  source  of  the  affection  to  the  sympathetic  nervous  sys- 
tem. He  believes  that  if  by  anxiety,  fatigue,  or  other  depressing  cause, 
the  regulating  influence  of  the  cerebro-spinal  system  of  nerves  is  im- 
paired, the  sympathetic  system,  no  longer  controlled,  runs  riot,  causing 
contraction  of  the  vessels  and  consequent  anaemia  of  the  brain.  It  is  to 
this  anaemia  that  he  attributes  the  disorders  of  sensation  which  precede 
the  cephalalgia.  Afterwards  the  excitement  of  the  sympathetic  subsides 
and  is  followed  by  exhaustion,  and  the  vessels  becoming  dilated  produce 
the  headache. 

Dr.  Edward  Living  differs  from  this  view.  This  authority  ascribes  aU 
the  phenomena  to  the  ii-reg-ular  accumulation  and  discharge  of  nerve-force. 
He  believes  that  a  "  nerve-storm  traverses  more  or  less  of  the  sensory 


MEGRIM — SYMPTOMS.  295 

tract  from  the  optic  thalami  to  tLe  ganglia  of  the  vagus,  or  else  radiates 
in  the  same  tract  from  a  focus  in  the  neighbourhood  of  the  quadrigeminal 
bodies." 

Symptoms. — The  cliief  symptom  of  megrim  is  headache.  Sometimes 
it  appears  to  be  the  sole  source  of  discomfort,  but  it  is  often  preceded  by 
a  general  feeling  of  illness  and  certain  disorders  of  sensation.  In  many 
cases  we  are  told  that  the  chUd  wakes  up  with  a  severe  headache,  and  that 
this  continues  for  several  hours,  during  which  he  lies  groaning  and  incapa- 
ble of  any  exertion  either  of  mind  or  body.  The  pain  in  young  subjects 
is  more  often  bilateral  than  it  is  in  older  persons,  and  is  comparatively 
seldom  limited  to  one  spot  or  one  side  of  the  head.  It  may  extend  across 
the  forehead  or  over  the  top  of  the  head  or  the  occiput.  It  is  of  a  very 
severe  throbbing  character,  and  is  increased  by  hght,  by  noise,  or  by 
movement.  The  child  feels  and  looks  excessively  depressed.  His  face  is 
pale  and  haggard.  He  cannot  eat,  and  usually  prefers  to  lie  quietly  on  a 
sofa  in  a  darkened  room.  His  head  is  often  hot,  but  his  feet  and  hands 
feel  cold  to  the  touch,  and  he  complains  of  feeling  chilly  and  may  shiver. 
The  pulse  is  small  and  weak  and  may  faU  to  60  or  70.  In  exceptional 
cases  the  child  feels  sick  and  may  vomit. 

The  headache  does  not  always  occur  in  the  early  morning.  Sometimes 
the  patient  wakes  up  in  his  usual  health,  and  it  is  not  until  several  hours 
afterwards  that  the  pain  begins.  The  cephalalgia  is  then  often  preceded 
by  curious  disorders  of  vision.  Some  children  will  say  that  objects  look 
small  to  them,  others  that  everything  appears  to  be  larger  than  natural. 
Sometimes  stationary  objects  seem  to  be  in  movement,  or  there  is  partial 
insensibility  of  the  retina,  so  that  the  patient  cannot  see  the  whole  of  an 
object  at  once.  Thus  in  looking  at  his  mother's  face  he  may  see  only  the 
right  or  the  left  side,  not  the  whole.  In  addition  to  the  sight,  other 
senses  may  be  affected.  There  may  be  noises  in  the  head  or  impairment 
of  hearing,  or  the  taste  or  smell  may  be  deficient.  The  child  complains 
of  unpleasant  odours,  or  if  offered  milk  remarks  upon  the  peculiarity  of 
its  flavour. 

These  earlier  symptoms  usually  subside  when  the  pain  comes  on.  The 
headache  lasts  a  variable  time,  from  three  or  four  to  eight  or  ten  hours, 
and  then  gradually  subsides.  As  his  suffering  becomes  relieved  the  child 
usually  falls  asleep  and  wakes  well,  but  wearied  and  weak.  The  frequency 
vnth  which  the  attacks  come  on  varies  in  different  subjects.  Often  they 
are  periodical  and  return  with  remarkable  regularity  every  week  or  fort- 
night. Sometimes  a  child  after  one  attack  has  no  return  of  the>  com- 
plaint for  months.  If  boys  at  school  suffer,  the  attacks  are  often  very 
frequent. 

Some  time  ago  I  saw  a  school-boy,  twelve  or  thirteen  years  of  age,  who 
was  subject  to  daily  headaches  to  such  a  degree  as  to  be  almost  incapaci- 
tated from  pursuing  his  education.  The  pain  began  in  the  morning  on 
rising  from  bed  and  lasted  all  day,  only  subsiding  towards  the  evening.  It 
pervaded  the  whole  of  the  head,  and  although  not  at  first  very  severe,  was 
made  worse  by  exercise,  by  head-work,  and  by  a  bright  light.  It  was  not 
attended  by  sickness.  If,  as  sometimes  happened,  the  boy  awoke  free 
from  pain,  the  cephalalgia  came  on  in  the  middle  of  the  day,  and  in  this 
case  did  not  subside  as  usual  in  the  evening.  The  boy  was  subject  about 
once  a  month  to  bilious  headaches,  but  these  he  described  as  different  to 
his  ordinary  pain.     In  the  latter,  objects  always  looked  large  to  him. 

There  was  no  doubt  about  the  truth  of  the  boy's  statements.  They 
were  corroborated  by  his  mother,  who  assured  me  that  the  severity  of 


296  DISEASE  IN   CHILDREN. 

her  son's  suffering  diuing  his  attacks  was  perfectly  visible  in  his  face.  The 
boy  himself  was  fond  of  his  studies  and  seemed  very  anxious  to  be  cured. 
He  first  took  ten-grain  guarana  powders,  but  without  relief.  He  was  then 
ordered  to  take  twice  a  day  a  dose  of  liq.  strychniiB  (TTl  iij.)  and  liquid 
extract  of  ergot  (TT[  x.),  and  in  a  few  days  the  headaches  had  entirely 
ceased. 

In  some  cases,  in  addition  to  the  cephalalgia  pains  apparently  of  a  neu- 
ralgic character  are  complained  of  in  the  limbs. 

A  well-grown  boy,  nine  years  old,  was  sent  to  me  from  the  Isle  of 
Wight  by  Dr.  Gibson,  with  the  history  that  for  six  months  he  had  been 
suffering  from  frequent  attacks  of  pain  in  the  head  and  often  in  the  legs. 
The  boy  used  frequently  to  cry  with  pain  which  attacked  him  at  night  in 
the  right  hip  and  knee.  He  was  noticed  to  drag  the  affected  leg  shghtly 
in  walking,  and  seemed  to  have  a  difiiculty  in  placing  the  foot  fairly  by  the 
side  of  the  other.  It  was  thought,  too,  that  the  leg  was  a  little  shortened. 
His  temperature  at  that  time  was  between  99°  and  100°.  The  pain  was 
not,  however,  confined  to  that  limb.  Sometimes  it  shifted  to  the  other 
extremity,  and  sometimes  was  complained  of  in  the  back  and  shoulder. 
The  temperature  for  a  month  was  about  100°,  but  the  boy  seemed  well 
except  for  the  pains,  and  strongly  objected  to  any  restriction  in  his  diet. 

When  the  patient  came  under  my  own  notice  he  was  in  good  condition 
and  had  a  healthy  appearance.  The  lungs  and  heart  were  normal,  and  the 
organs  generally  gave  no  sign  of  disease.  The  urine  was  acid,  of  specific 
gravity  1.014,  and  contained  no  albumen.  No  petechise  or  signs  of  bruis- 
ing were  seen  about  the  body.  There  was  no  sweUing  of  any  of  the  joints, 
nor  any  excess  of  fluid  in  the  knees.  The  attacks  of  pain  were  said  to 
come  on  at  variable  intervals.  Often  he  woke  in  the  morning  with  a  se- 
vere frontal  headache,  but  sometimes  the  cephalalgia  came  on  during  the 
day.  It  always  lasted  many  hours.  He  rarely  vomited.  When  the  pain 
first  began  in  the  course  of  the  day,  he  was  noticed  for  some  time  before- 
hand to  look  white,  with  eyes  "  drawn,"  and  his  sight  would  be  affected. 
He  would  see  only  half  an  object,  or  objects  would  look  unnaturally  small 
to  him.  In  the  limbs  the  pains  were  chiefly  at  this  time  behind  the  knees, 
but  sometimes  they  affected  the  thighs  and  calves  of  the  legs.  They  ^vere 
increased  by  exercise,  and  he  could  not  walk  long  without  fatigue.  His 
appetite  was  good  and  his  bowels  were  regular.  The  boy  was  ordered  to 
take  two  minims  of  liq.  strychnise  and  fifteen  of  the  liquid  extract  of 
ergot  three  times  a  day,  and  the  nurse  was  directed  to  employ  vigorous 
frictions  to  his  limbs  before  he  went  to  bed.  Under  this  treatment  the 
distressing  symptoms  began  to  moderate,  and  as  long  as  the  boy  remained 
in  London— a  period  of  several  weeks — he  had  no  return  of  the  headache 
or  pains  in  the  Hmbs.  Before  his  return  home  he  was  said  to  have  greatly 
improved  in  his  power  of  walking. 

Diagnosis. — Periodical  attacks  of  headache,  preceded  by  disorder  of 
sight — these  attacks  lasting  several  hours  and  passing  off  completely,  leav- 
ing the  child  well  until  the  next  recurrence — may  almost  always  be  ascribed 
to  megrim.  Children  comparatively  rarely  suffer  from  dyspeptic  head- 
aches, although  sometimes  during  attacks  of  acid  indigestion  in  young 
subjects  dull  pain  in  the  temples  and  soreness  of  the  eyeballs  may  be 
complained  of.  These  attacks  are,  however,  very  different  from  megrim. 
The  pain  is  much  less  intense  and  is  preceded  by  symptoms  of  gastric  de- 
rangement ;  the  tongue  is  foul ;  the  bowels  are  confined  ;  the  patient  looks 
heavy,  and  his  complexion  is  usually  sallow.  In  megrim  the  pain  is  intense 
and  throbbing,  the  face  is  white,  and  vomiting,  if  it  occur,  is  a  late  symp- 


MEGEIM — DIAGNOSIS — TEEATMENT.  297 

torn,  coming  on  towards  the  end  of  the  attack.  The  attacks,  too,  often 
occur  in  the  night,  so  that  the  patient,  when  he  wakes  up,  finds  the 
headache  fully  developed,  although  he  had  retired  to  rest  in  perfect 
health. 

Children  who  are  much  exposed  to  vitiated  air,  especially  to  air  made 
unwholesome  by  gas-jets,  often  suffer  from  headaches,  but  in  these  cases 
the  pain  can  be  traced  to  the  evident  cause  of  the  attack.  Again,  hyper- 
metropia  is  a  not  uncommon  cause  of  cephalalgia  in  young  people.  This 
form  of  headache  is  not  noticed  until  the  education  of  the  child  is  entered 
upon  and  he  begins  to  pursue  regular  studies.  He  is  then  forced  for 
some  hours  together  to  exert  the  full  focussing  power  of  his  eyes  in  order 
to  remedy  his  natural  defect,  and  the  consequent  strain  upon  his  muscles 
of  accommodation  gives  rise  to  a  frontal  headache  which  is  often  very  dis- 
tressing. But  this  headache  always  comes  on  at  about  the  same  time  in 
the  day,  and  is  evidently  connected  with  the  act  of  reading.  It  ceases 
at  once  directly  the  hypermetropia  is  remedied  by  the  use  of  suitable 
glasses. 

In  headache  due  to  cerebral  disease,  such  as  tumour  of  the  brain,  there 
are  usually  other  symptoms  connected  with  the  brain  which  continue  be- 
tween the  attacks  of  paroxysmal  suffering.  Squint,  or  nystagmus,  is  often 
an  early  symptom,  and  persistent  lesions  of  special  sense  soon  begin  to 
be  observed.  These  are  not  limited  to  the  seizures,  but  continue  after  the 
headache  has  subsided. 

Treatment. — During  the  actual  attack  the  child  should  be  allowed  to 
lie  quietly  in  a  room  shaded  from  a  too  bright  Hght.  If  he  be  chilly  a 
thin  coverlet  may  be  thrown  over  him,  and  if  his  feet  feel  cold  they 
should  be  warmed  by  a  hot-water  bottle.  The  best  remedy  at  this  stage 
is  the  guarana  powder,  which  is  to  be  given  in  a  dose  of  ten  gTains  (to  a 
■child  of  ten  years  old)  in  a  little  sweetened  water.  This  remedy  is  said 
to  succeed  best  in  cases  where  there  are  very  distinct  premonitory  symp- 
toms, especially  disorders  of  vision,  but  even  in  these  cases  the  adminis- 
tration of  the  powder  is  often  followed  by  no  relief.  Other  remedies 
which  sometimes  have  the  effect  of  cutting  short  an  attack  are  the  bromide 
of  potassium  (gr.  x.-xx.)  with  sal  volatile,  chloride  of  ammonium  (gr. 
X.-XV.)  with  spirits  of  chloroform,  and  compound  tincture  of  lavender. 
Various  antispasmodics,  as  valerian,  assafoetida,  tincture  of  henbane,  and 
the  fetid  spirits  of  ammonia,  have  also  been  recommended.  In  many 
•cases — in  most,  perhaps,  occurring  in  young  subjects — the  attack  is  very 
decidedly  shortened  by  a  dose  (tt[  xv.-xx.)  of  the  liquid  extract  of  ergot 
given  with  spirits  of  chloroform  in  camphor- water. 

If  sickness  occur  and  prove  obstinate,  it  may  be  often  arrested  by  a 
sahne  effervescing  draught  containing  a  couple  of  drops  of  dilute  hj^dro- 
cyanicacid  (P.  B.). 

After  the  attack  is  at  an  end  the  child  should,  if  possible,  avoid  close 
rooms  and  headwork,  and  should  be  made  to  spend  as  much  of  his  time  as 
possible  in  the  open  air.  In  the  case  of  school-boys,  however,  it  is  impor- 
tant that  their  education  should  be  proceeded  with,  and  we  must  endeavour 
to  arrest  the  tendency  to  the  attacks  without  any  intermission  of  study. 
-Few  cases  will  be  found  to  resist  the  combination  of  strj^chnia  and  extract 
■of  ergot  ah'eady  referred  to  in  the  treatment  of  the  two  cases  which  have 
been  narrated.  I  was  led  to  employ  these  remedies  in  this  complaint  from 
noticing  their  useful  effects  in  some  cases  of  epilepsy,  and  since  beginning 
to  treat  megrim  in  the  young  subject  by  this  method  I  have  met  with  very 
few  obstinate    cases.     Often  from   the   time   of   beginning  to   take   the 


298  DISEASE  IN   CHILDEEN. 

medicine  the  attacks  have  ceased  altogether.  I  usually  order  two  or  three 
drops  of  the  strychnia  solution  (P.  B.)  and  ten  or  fifteen  of  the  Uquid 
exti-act  of  ergot  with  spirits  of  chloroform  to  be  taken  three  times  a  day. 
I  beheve  the  combination  of  the  two  drugs  to  be  more  efficacious  than 
either  given  alone,  but  in  some  cases  strychnia  given  with  iron  has  been 
found  of  value. 

The  child's  bowels  must  be  kept  regular  with  some  ndld  aperient,  such 
as  the  compotmd  liquorice  powder,  and  the  diet  should  be  regulated, 
taking  care  that  he  does  not  take  an  excess  of  sweets  or  fruit 


CHAPTEE  YII. 

CHOREA. 

Chorea  is  essentially  a  disease  of  tlie  second  dentition  ;  for  although  it  is 
occasionally  met  with  in  children  under  five  years  of  age,  and  sometimes 
even  in  adults,  yet  an  enormous  majority  of  the  cases  are  found  between 
the  ages  of  five  and  fifteen  years. 

Causation. — Children  who  are  likely  to  be  attacked  by  this  complaint 
are  those  in  whose  family  there  is  a  tendency  to  neurotic  disease,  and  who, 
perhaps  as  a  consequence  of  this  tendency,  are  born  delicate  and  sensitive, 
with  a  highly  impressionable  nervous  system.  Perhaps  the  mother  may 
herself  in  childhood  have  been  afflicted  in  the  same  way.  Girls  are 
much  more  prone  to  it  than  boys,  and  a  child  who  has  once  passed 
through  an  attack  is  very  likely  to  suffer  from  it  a  second  time. 

The  outbreak  of  the  disorder  may  be  determined  by  an  attack  of 
rheumatism,  or  by  some  shock  to  the  nervous  system,  as  a  fright,  or  by 
any  cause  which  reduces  the  strength  more  or  less  suddenly  and  sets  up 
anaemia  or  some  cachectic  condition.  There  is  an  indisputable  connection 
between  rheumatism  and  chorea.  It  is  common  to  find  a  family  history 
of  rheumatic  attacks.  Often  the  patient  has  herself  suffered  from  it,  either 
in  its  acute  or  subacute  form.  Out  of  forty-two  cases  (nine  boys  and 
thirty-three  girls)  of  whom  I  have  notes,  I  find  distinct  history  of  rheumatic 
attacks  in  sixteen.  Others  came  of  rheumatic  families,  although  it  could 
not  be  discovered  that  they  had  suffered  from  the  disease  themselves. 
There  was  a  heart-murmur  in  twenty-seven,  and  in  many  cases  the  rheu- 
matic disease  had  left  evident  traces  of  its  passage  in  a  harsh  cardiac 
murmur  with  some  hypertrophy  of  the  heart.  Still,  there  is  no  doubt 
that  we  find  many  cases  of  chorea  in  which  no  history  of  rheumatism  can 
be  discovered,  and  many  rheumatic  children  never  have  chorea.  Eheuma- 
tism  alone  will  not  set  up  the  complaint,  for  a  peculiar  instability  of  the 
nervous  system  is  no  doubt  essential  to  the  production  of  the  disorder. 
Eilliet  states  that  in  Geneva,  where  rheumatism  was  a  common  disease, 
chorea  was  almost  unknown,  and  according  to  the  investigations  of  Dr. 
Weir  Mitchell,  it  appears  that  amongst  negro  children,  in  whom  i-heu- 
matism  is  not  uncommon,  chorea  is  very  rarely  seen. 

Di'.  Anstie  was  of  opinion  that  the  hereditary  rheumatic  tendency  was 
associated  with  a  hereditary  tendency  to  neurotic  diseases  of  various  kinds, 
and  especially  to  chorea.  In  support  of  this  view  he  instanced  the  case 
of  nine  families  with  decided  rheumatic  history.  In  each  of  these  several 
of  the  children  had  suffered  from  rheumatism,  to  his  own  personal 
knowledge.  In  all  of  them,  also,  there  was  a  strong  neurotic  inheritance, 
which  showed  itself  in  many  cases  in  the  form  of  chorea.  The  striking 
fact  consisted  in  this,  that  although  many  children  suffered  from  rheu- 
matism and  many  from,  chorea,  it  was  not  the  victims  of  rheumatism  who 
were  especially  prone  to  chorea.     As  often  as  not  those  children  who  had 


300  DISEASE  1^   CHILDEElSr. 

suffered  from  rheumatism  escaped  the  neurosis,  while  others  who  had 
never  had  rheumatism  fell  victims  to  chorea. 

Other  conditions  appear  to  influence  the  incidence  of  the  disease.  The 
rarity  of  chorea  amongst  the  little  negroes  seems  to  show  that  the  degi-ee 
of  cerebral  development  may  constitute  an  important  element  in  the  ten- 
dency to  the  disorder  ;  for  the  brain  in  the  black  race  is  no  doubt  less 
perfectly  developed  than  it  is  in  whites.  Again,  monotony  of  life  and  ab- 
sence of  mental  excitement  must  tend  to  impart  immunity  from  chorea, 
for  Dr.  Weu'  Mitchell's  researches  show  that  the  disease  is  far  less  common 
in  rural  districts  than  it  is  in  towns,  and  in  small  towns  than  in  large  cities. 

In  a  suitable  subject  any  irritant  may  set  up  the  complaint.  Worms 
in  the  intestinal  canal,  and,  of  course,  the  practice  of  masturbation,  have 
been  cited  as  frequent  causes  of  this  as  of  all  other  nervous  disorders. 
Still,  I  cannot  but  think  that  the  influence  of  the  two  causes  just  mentioned, 
of  masturbation  especially,  in  provoking  nervous  derangements  in  the  child 
has  been  greatly  exaggerated.  Chorea  is  sometimes  associated  with  grave 
diseases  of  the  ner^^ous  centres.  It  has  been  seen  in  connection  with  cere- 
bral tubercle,  cerebral  hypertrophy,  and  softening  of  the  brain  ;  and  Dr. 
Jacoby  has  reported  a  case  in  which  "siolent  choreic  movements  were  in- 
duced by  meningitis  involving  the  membranes  of  the  cervical  part  of  the 
spinal  cord. 

Pathology. — The  pathology  of  chorea  is  still  a  matter  of  debate.  In 
some  fatal  cases  obstructions  have  been  discovered  in  the  minute  arteries 
ramifying  in  the  corj)us  striatum  and  its  vicinity,  mth  little  points  of  soft- 
ening and  congestion  resulting  from  them.  Hence  Dr.  Kirke's  view, 
since  supported  by  the  authority  of  Dr.  Hughlings  Jackson,  that  chorea  is 
a  consequence  of  minute  emboli  swept  out  of  the  heart  and  arrested  in  the 
small  arteries  of  this  part  of  the  brain.  This  theory,  if  correct,  would  only 
explain  the  cases  which  have  been  preceded  by  rheumatism,  and  would 
throw  no  light  on  the  many  cases  where  the  heart  is  to  all  appearance 
healthy. 

Dr.  Dickinson  has  proposed  another  explanation.  He  believes  that  the 
faulty  part  of  the  brain  is  not  hmited  to  so  small  an  area.  In  his  opinion 
the  disease  depends  upon  a  wide-spread  hyperaemia  of  the  nervous  centres 
"not  due  to  any  mechanical  mischance,  but  produced  by  causes  mainly  of 
two  kinds — one  being  the  rheumatic  condition,  the  other  comprising  vari- 
ous forms  of  irritation,  mental  and  reflex,  belonging  especially  to  the  ner- 
vous system."  Dr.  Dickinson  has  found,  as  the  result  of  post-mortem  ex- 
aminations of  fatal  cases,  that  all  the  small  arteries  both  of  the  brain  and 
spinal  cord  have  a  general  tendency  to  dilatation.  As  a  consequence,  exu- 
dations and  sometimes  minute  haemorrhages  occur  in  the  tissues  immedi- 
ately surrounding  the  dilated  vessels — shown  by  the  presence  of  blood- 
crystals  and  patches  of  sclerosis.  He  has  noticed  these  changes  to  be  most 
advanced  in  the  corpora  striata,  the  vicinity  of  the  trunks  of  the  middle 
cerebral  arteries,  and  in  the  posterior  and  lateral  parts  of  the  spinal  cord 
— principally  at  the  upper  part ;  and  states  that  they  are  equally  distrib- 
uted on  the  two  sides.  This  theory  has  the  advantage  that  it  explains  the 
wasting  of  muscles,  rigidity  of  limbs,  and  occasional  permanent  paralyses 
which  sometimes  follow  an  attack  of  chorea. 

In  opposition  to  the  above  theories  based  upon  morbid  anatomy,  Dr. 
Sturges  has  advanced  an  ingenious  explanation  of  the  phenomena  attend- 
ant upon  chorea,  founded  upon  intimate  acquaintance  with  the  peculiarities 
of  childhood.  Dr.  Sturges  regards  chorea  as  a  purely  functional  complaint, 
arising,  in  the  majority  of  cases,  from  some  strong  nervous  impression. 


CHOKEA — PATHOLOGY — SYMPTOMS.  301 

Starting  from  the  fact  that  in  every  child  placed  in  an  embarrassing  posi- 
tion emotional  restlessness  (or  temporary  chorea)  is  produced,  he  argues 
that  exaggerated  limb-movement  is  the  natural  expression  in  young  sub- 
jects of  emotional  states;  that  disordered  movement  is  increased  by  the  at- 
tention being  diverted,  as  it  is  by  some  strong  emotional  shock  ;  that  the 
consciousness  of  this  partial  loss  of  control  deepens  the  mental  impression 
and  intensifies  and  extends  its  consequences  ;  and,  lastlj',  that  want  of  suc- 
cess in  directing  movement  imj)airs  the  child's  confidence  and  entails  fur- 
ther failure.  The  little  treatise  is  well  worthy  of  perusal,  for  although  it 
may  not  offer  a  full  explanation  of  all  the  phenomena  connected  with  the 
disorder,  no  one  can  refuse  admiration  to  the  ingenuity  of  its  reasoning 
and  the  graces  of  its  style. 

Dr.  Haydon,  of  Dublin,  has  started  another  theoiy.  Like  Dr.  Sturges 
he  refuses  to  accept  any  special  organic  lesion  as  the  exciting  cause  of  the 
complaint.  He  believes  that  the  attack  begins  with  a  vaso-motor  paresis^ 
the  consequence  of  a  profound  emotional  impression,  and  that  the  essen- 
tial symptoms  are  due  to  defective  polarity  or  dynamic  instability  of  the 
motor-nerve  tracts,  both  intracranial  and  spinal.  This  hypothesis  woiold. 
explain  the  post-mortem  appearances  noted  by  Dr.  Dickinson,  and  would, 
account  for  the  phenomena  common  in  the  graver  cases  of  the  disorder. 

Symptoms. — The  phenomena  of  chorea  consist  in  an  inabihty  to  guide 
and  control  the  muscles,  so  that  while  there  is  excess  of  motion  there  is. 
absence  of  ordered  movement.  The  infirmity  begins  gradually  in  most 
cases.  At  first  the  child  is  noticed  to  be  stupid  over  her  lessons ;  she 
shows  less  than  her  usual  alacrity  at  her  games,  and  is  emotional,  nervous, 
and  altogether  strange  in  manner.  Soon  she  begins  to  fidget,  scrajping 
her  feet  as  she  sits  on  a  chau",  or  restlessly  moving  one  of  her  hands  about 
her  dress.  Then  she  is  found  to  drop  articles  from  her  hand,  and  to 
stumble  awkwardly  as  she  walks.  These  symptoms  are  always  at  first 
attributed  to  carelessness,  and  the  child  is  admonished  and  reproved  ;  but 
after  a  time,  usually  from  some  eccentricity  of  movement  or  facial  contor- 
tion, it  dawns  upon  the  parents  that  the  child's  control  over  her  muscles  is 
impaired,  and  the  matter  is  referred  to  the  medical  attendant. 

In  exceptional  cases  the  symptoms  do  not  come  on  in  this  insidious 
way,  but  begin  with  some  suddenness  as  a  consequence  of  fright  or  other 
shock  to  the  nervous  system.  But  however  the  disorder  may  have  begun, 
when  fully  developed  the  symptoms  are  the  same.  The  power  of  the  will 
to  control  muscular  action  appears  to  be  completely  lost,  and  we  find 
spontaneous  spasmodic  movement,  inco-ordination  of  voluntary  movement, 
and  a  certain  degree  of  muscular  weakness. 

In  a  marked  case  nearly  all  the  voluntary  muscles  of  the  body  seem  to 
take  their  share  in  this  disorder  of  movement.  The  child  is  never  quiet. 
First  one  group  of  muscles,  then  another,  contract  in  a  jerky  spasmodic 
manner  which  is  very  characteristic.  Volition  is  evidently  not  concerned 
in  their  production.  They  occiu:  not  only  without  the  influence  of  the 
will,  but  in  spite  of  it.  The  face  is  curiously  worked,  as  if  the  muscles 
were  attempting,  but  unsuccessfully,  to  simulate  all  the  passions  of  the 
mind.  The  eyebrows  are  suddenly  bent  into  a  frown  ;  but  it  is  not 
anger.  The  mouth  expands  abruptly  into  a  smile ;  but  conveys  no  im- 
pression of  mirth.  The  eyehds  are  opened  widely  ;  then  quickly  squeezed 
together ;  the  eyes  are  rolled  upwards,  downwards,  and  from  side  to  side  ; 
the  cheeks  twitch,  and  the  angles  of  the  mouth  are  contorted  with  strange 
grimaces.  The  head  is  jerked  backwards  and  forwards,  and  then  pulled 
suddenly  down  to  one  side.     The  arm  may  be  thrown  abruptly  forwards 


t^02  DISEASE  IN   CHILDREN. 

'by  a  peculiar  movement  of  the  shoulder  ;  the  hand  and  wrist  are  violently 
j)ronated,  then  as  suddenly  supinated,  and  the  fingers  work  convulsively. 
Sometimes,  by  a  strong  efibrt  of  the  will,  the  hand  may  be  kept  quiet  for 
a  few  seconds,  but  soon,  vnth  a  convulsive  jerk,  it  is  throvTn  again  into 
motion.  The  lower  limbs,  although  less  violently  affected,  are  not  inac- 
tive. They  are  thrown  one  over  the  other,  or  are  suddenly  drawn  up  and 
a,gain  extended. 

Sometimes  the  muscles  of  the  trunk  may  be  affected,  and  spasmodic 
contractions  of  the  respiratory  muscles  may  take  place  ;  or  the  patient 
may  be  suddenly  jerked  upwards  from  the  bed,  or  even  thrown  out  of  it 
upon  the  floor.  In  the  worst  cases  the  child  has  a  wild,  frightened  look, 
or  sometimes  a  half- dazed  expression  ;  speech  may  be  impossible,  and  even 
memory  may  appear  to  be  almost  lost. 

In  the  milder  cases  an  effort  to  execute  a  voluntary  act  increases  the 
contractions ;  and  even  the  exertion  of  standing  makes  control  of  the 
nauscles  more  difficult.  The  more  completely  the  child  is  at  rest,  the 
quieter  she  becomes.  The  movements  are  also  increased  by  mental  emo- 
tion and  nervousness,  so  that  the  child  is  always  at  her  worst  when 
observed ;  and  no  doubt,  as  Dr.  Sturges  suggests,  the  consciousness  of 
failure  increases  her  helplessness.  During  the  height  of  the  complaint 
the  ungovernable  eccentricity  of  movement  makes  the  commonest  actions 
difficult  or  impossible  ;  for  an  attempt  to  direct  any  special  group  of  muscles 
is  immediately  frustrated  by  violent  contractions  of  antagonistic  groups,  so 
that  the  patient  does  anything  but  what  she  wishes.  The  child  can  only 
speak  indistinctly ;  she  cannot  button  or  tie  her  clothes,  or  perform  any 
act  in  which  accurate  co-ordination  of  movement  is  required.  For  this 
reason  it  is  often  quite  impossible  for  her  to  feed  herself,  as  she  can  no 
longer  guide  the  spoon  or  fork  to  her  Hps.  Even  when  fed  by  the  nurse, 
mastication  may  be  difficult  from  irregular  movements  of  the  tongue  ;  and 
sometimes  the  contractions  of  the  gullet  are  interfered  with  in  the  process 
of  swallowing.  In  bad  cases  natural  sleep  is  almost  impossible.  Even  in 
a  milder  form  of  the  complaint  the  child  finds  a  difficulty  in  going  to  sleep  ; 
but  when  she  does  at  last  sleep  the  movements  cease. 

Sometimes  sensory  disturbances  can  be  noticed.  Painful  spots  may  be 
found  in  the  course  of  the  nerve-trunks  in  the  affected  parts ;  there  may 
be  tenderness  on  pressure  over  the  spinous  processes  of  the  vertebrae  ;  or 
the  child  may  complain  of  hypersesthesia  or  ansesthesia  of  the  skin.  Occa- 
sionally sight  is  impaired. 

The  choreic  movements  are  not  always  general ;  sometimes  they  are 
limited  to  one-half  of  the  body  (hemichorea).  In  these  cases  either  sj.de 
may  be  attacked  ;  but  even  in  hemichorea,  according  to  Dr.  Broadbent, 
muscles  bilaterally  associated  in  their  action  are  affected  to  some  extent  on 
the  two  sides.  When  the  disorder  is  unilateral,  the  muscular  weakness, 
which  is  seldom  completely  absent,  is  more  easy  to  recognise,  as  we  have 
in  the  sound  side  a  standard  of  comparison.  When  sensation  is  impaired 
in  hemichorea,  it  is  impaired  on  the  same  side  of  the  body  as  that  on 
which  the  muscles  are  affected.  This  fact  is  relied  upon  by  Dr.  Broadbent 
as  a  proof  that  the  seat  of  the  disease  is  not  in  the  cord  ;  for  if  it  were  so, 
sensation  would  be  impaired  on  the  side  opposite  to  the  affected  muscles. 

The  constant  movement  seems  to  cause  wonderfully  little  muscular 
fatigue.  In  ordinary  cases,  if  the  movements  are  not  exceptionally  violent 
the  general  health  is  but  little  affected.  The  child  may  complain  of  gid- 
diness '  and  headache,  but  appetite  is  usually  good,  and  the  digestive 
functions  are  well  performed,  although  the  bowels  may  be  costive.     In  bad 


CHOEEA — SYMPTOMS.  303 

cases  appetite  is  often  capricious  and  digestion  impaired,  and  partly  for 
this  reason,  partly  from  the  difficulty  in  feeding  the  patient  and  the  want 
of  sleep,  nutrition  may  suffer  and  the  child  become  pale  and  thin. 

The  urine  has  always  a  high  specific  gravity  at  the  height  of  the  dis- 
ease, and  contains  abundant  urea  and  phosphates. 

The  mental  condition  may  vary,  according  to  the  severity  of  the  dis- 
order, from  mere  depression  or  irritability  to  taciturnity,  obstinacy,  vio- 
lence of  disposition,  or  even  furious  delirium.  In  the  milder  cases  intelli- 
gence does  not  appear  to  be  enfeebled,  and  although  the  patient  often  has 
a  silly  vacant  expression,  this  is  no  more  than  can  be  accounted  for  by  the 
child's  own  feeling  of  helplessness,  and  her  consciousness  that  her  contor- 
tions and  grimaces  may  be  the  subject  of  ridicule. 

The  temperature  in  chorea  is  normal  unless  the  complaint  be  compli-  ■ 
cated  with  a  rheumatic  attack,  or  be  symptomatic  of  organic  disease  of  the 
nervous  centres. 

Weakness  of  the  muscles  has  already  been  referred  to  as  an  essential 
symptom  of  the  disorder,  but  as  a  rule  it  is  insignificant,  and  may  not  be 
noticed  without  special  inquiry.  Sometimes,  however,  the  muscular  weak- 
ness assumes  great  prominence,  and  may  even  throw  all  the  other  symp- 
toms into  the  shade.  Thus  a  form  of  the  disease  is  sometimes  met  with 
in  which  a  paralysis  or  paresis  of  one  or  more  limbs  is  the  only  symptom 
complained  of.  For  instance,  a  little  girl  is  said  to  have  gradually  lost  the 
use  of  her  arm.  The  hand  hangs  down  and  is  evidently  very  weak.  The 
patient  may  perhaps  by  a  great  effort  of  will  be  able  to  raise  it,  but  when 
she  tries  to  grasp  with  the  fingers  the  pressure  is  very  feeble.  The  leg  of 
the  same  side  is  sound,  and  there  is  no  paralysis  of  the  face  or  tongue. 
Sometimes  the  other  arm  is  also  weak,  although  to  a  less  degree.  In  other 
cases  the  paralysis  involves  the  leg  as  well  as  the  arm  of  one  side,  but  the 
face  and  tongue  always  escape.  In  all  these  cases,  although  to  a  casual 
glance  there  may  appear  to  be  no  movement  at  all,  careful  inspection  will 
usually  discover  occasional  slight  twitches — faint  cIodIc  spasms — in  the 
affected  limb  or  on  the  sound  side.  Sometimes  this  is  all  that  can  be 
noticed,  and  the  muscular  power  returns  after  a  time  without  the  occur- 
rence of  any  confirmed  disorder  of  movement.  In  other  cases  the  clonic 
spasms  become  more  and  more  marked  as  the  paresis  improves,  so  that 
when  the  power  of  the  affected  limb  is  almost  restored  the  motor  disorder 
is  at  its  height. 

There  is  another  form  of  muscular"  weakness  which  occurs  later,  and 
sometimes  remains  as  a  permanent  condition  after  the  disease  has  passed 
off.  It  affects  the  muscles  which  have  been  previously  implicated,  and  is 
probably  due  to  degenerative  changes  in  the  spinal  cord.  The  muscles 
remain  weak  and  become  wasted,  and  perhaps  contracted. 

The  state  of  the  heart  in  chorea  is  very  interesting.  In  a  large  propor- 
tion of  cases,  at  least  of  those  occurring  in  young  children,  a  mitral  mur- 
mur becomes  developed  in  the  course  of  the  illness.  This  murmur  may 
disappear  as  the  symptoms  of  motor  disorder  decline,  or  may  remain  as  a 
permanent  condition.  The  temporary  murmurs  are  often  very  variable  in 
intensity  ;  coming  and  going  ;  heard  with  some  beats  of  the  heart  and  not 
with  others.  These  are  probably  due  to  some  irregular  action  of  the 
papillary  muscles  of  the  heart,  the  consequence  of  clonic  spasm  similar  to 
that  which  takes  place  in  the  voluntary  muscles  of  the  body.  Temporary 
murmurs,  when  not  thus  interrupted,  may  be  the  result  of  anaemia — a 
condition  in  which  the  blood  is  watery  and  the  tissues  of  the  heart  relaxed, 
so  that  the  left  ventricle  is  dilated  and  the  mitral  orifice  is  insufficiently 


304  DISEASE  IN   CHILDEEN". 

closed  by  its  valve.  In  these  cases  there  is  often  a  basic  pulmonary  mur- 
mur. We  cannot  say  positively  that  a  murmur  has  disappeared  until  we 
have  examined  the  chest  after  exertion  as  well  as  when  the  heart  is  quiet. 
It  is  important,  therefore,  before  pronouncing  an  opinion,  to  excite  the 
heart's  action  by  making  the  child  run  round  the  room.  If  the  heart-sounds 
after  this  exercise  still  remain  clear,  we  can  say  decidedly  that  the  miirmur 
has  gone.  Temporary  murmurs  are  much  more  common  in  girls  than  in 
boys. 

Permanent  murmui's  are  in  all  cases,  probably,  the  result  of  endocar- 
ditis, which  may  be  due  to  coincident  rheumatism,  or  may  arise  in  the 
course  of  the  illness  without  rheumatic  taint. 

The  choreic  disorder  runs  a  chronic  course,  but  in  the  large  majority 
of  cases  ends  in  complete  recovery.  Its  progress  is,  however,  often  un- 
equal, and  the  child  may  be  better  and  worse  again  several  times  before 
control  over  muscular  movement  is  completely  restored.  After  aU  in- 
voluntary spasm  has  subsided,  a  certain  abruptness  of  executing  voluntary 
acts  may  continue  for  a  time  before  all  traces  of  the  disorder  pass  away. 
Relapses  after  an  interval  of  months  or  years  are  very  common. 

The  duration  of  chorea  varies  greatly.  If  left  to  itself  it  lasts  from  one 
to  two  months,  seldom  longer,  although  cases  are  recorded  in  which  mus- 
ciilar  disturbance  has  continued  through  life.  As  a  rule,  the  disease  can 
be  greatly  influenced  by  treatment.  "When  the  complaint  passes  off,  recov- 
ery in  most  cases  is  complete.  Sometimes,  however,  the  mind  remains 
more  or  less  enfeebled ;  the  patient  becomes  slovenly,  careless,  and  dirty 
in  her  habits,  and  may  even  drift  into  a  state  of  permanent  weakness  of 
mind.  In  other  cases  the  contrary  happens,  and  the  intellect  seems  bright- 
ened by  the  attack.  Sometimes,  although  fortunately  veiy  rarely,  some  of 
the  affected  muscles  undergo  atrophy  and  contraction. 

Death  from  the  disease  is  very  uncommon  in  childi-en,  but  it  sometimes 
occiu'S  from  the  violence  of  the  disease,  the  patient  being  worn  out  by 
want  of  sleep,  insufficient  nourishment,  and  muscular  exhaustion.  Death 
is  usually  preceded  by  delirium  and  coma.  In  the  bad  cases  the  chafing 
of  the  skin  produced  by  constant  friction  becomes  a  source  of  great  dis- 
comfort, and  may  induce  an  attack  of  fatal  erysipelas. 

Diagnosis. — Li  a  well-marked  case  of  chorea  the  absence  of  monotony 
and  rhythm  in  the  movements,  their  abruptness  and  variety,  their  com- 
plete independence  of  the  will,  and  their  occurrence  in  spite  of  all  efforts 
to  restrain  them,  make  mistake  impossible.  The  cases  which  begin  with 
paresis,  and  in  which  the  muscular  movement  is  a  subordinate  and  insig- 
nificant feature,  are  less  immediately  recognisable.  In  such  cases  careful 
observation  is  often  required  to  ascertain  the  existence  of  muscular  spasm. 
According  to  Dr.  Gowers,  whenever  a  child  of  the  choreic  age  suffers  from 
gradual  loss  of  power  in  the  arm,  and  presents  no  weakness  of  face, 
tongue,  or  leg,  the  disease  is  invariably  chorea.  If  the  nature  of  the  com- 
plaint be  suspected,  we  must  look  for  confiimatoiy  evidence,  and  shght  oc- 
casional spasm  will  be  usually  detected  in  the  weak  arm  or  in  the  sound 
one. 

Prognosis. — The  immediate  prognosis  is  almost  always  favourable,  and 
very  severe  cases  in  children  under  twelve  years  of  age  seldom  do  other- 
wise than  well.  The  worst  cases  are  seen  in  gii'ls  who  have  menstruated, 
and  it  must  be  remembered  that  the  catamenia  sometimes  appears  at  a 
very  early  age. 

The  influence  of  the  disease  upon  a  child's  future  hfe  has  also  to  be 
considered.     If  the  patient  have  strong  neurotic  tendencies  derived  from 


CHOREA — TREATMENT.  305 

inheritance,  we  may  feel  less  sanguine  tiian  we  otherwise  should  be  as  to 
the  after-effects  of  the  illness.  In  such  cases  much  will  depend  upon  the  moral 
influences  which  may  be  brought  to  bear  upon  the  child.  The  form  of 
the  complaint  in  wliich  muscular  weakness  is  the  prominent  and  early 
symptom,  seldom  passes  into  very  severe  general  chorea,  but  it  often 
proves  an  obstinate  ailment  and  difficult  of  cure. 

Treatment. — Choi'ea  is  a  disease  which  is  decidedly  influenced  by  treat- 
ment in  the  wider  sense  of  the  word,  as  distinguished  from  mere  drug- 
giving.  Our  first  care  should  be  to  see  that  the  muscles  are  spared  all  un- 
necessary exertion  ;  and  that  the  child  is  kept  as  quiet  as  possible  in 
bed.  We  should  then  attend  to  all  the  bodily  functions — see  that  the 
bowels  are  regularly  reUeved  ;  that  any  worms  present  in  them  are  re- 
moved ;  that  the  skin  and  kidneys  act  well ;  that  the  diet  is  regu- 
lated "with  a  proper  proportion  of  animal  and  vegetable  substances ;  and 
that  the  child  does  not  take  too  much  farinaceous  matter  or  sweets.  In 
most  cases  the  subjects  of  chorea  are  antemic  and  weak,  with  flabby  mus- 
cles ;  not  unfrequently  the  skin  is  dry  and  acts  imperfectly.  To  re- 
store the  skin  to  its  natural  condition  the  body  should  be  oiled  all  over 
at  night,  and  in  the  morning  the  child  should  be  thoroughly  washed  with 
soap  and  hot  water.  After  a  few  days  the  normal  softness  and  suppleness 
of  the  skin  vnll  be  restored.  A  cold  douche  may  be  then  added  to  the 
treatment.  If  the  child  be  not  weakly,  the  douche  may  be  given  after  her 
ordinary  bath  as  she  sits  in  the  warm  water.  In  the  case  of  a  weakly 
child  it  is  better  to  separate  the  ordinary  washing  from  the  invigorating 
douche.  The  patient  may  take  her  usual  bath  in  the  evening,  and  in  the 
morning  the  douche  may  be  given  as  the  child  sits  in  hot  water,  after 
complete  preparation  of  the  skin  by  vigorous  shampooing  (see  Litroduc- 
tion).  In  this  process  the  shampooing,  besides  preparing  the  skin  to  resist 
the  shock  of  the  cold  water,  seems  to  have  a  directly  beneficial  effect  upon 
the  muscles. 

Moral  treatment  is  of  the  utmost  importance.  The  child  is,  as  a  rule, 
weakened  and  demoralised  by  the  new  conditions  in  which  she  finds  her- 
self, and  much  may  be  done  by  kindness,  firmness,  and  vigilant  attention 
to  her  wants  to  restore  the  balance  of  her  mind.  At  first  she  should  be 
amused  as  much  as  possible,  and  endeavours  should  be  made  to  anticipate 
her  wishes,  so  that  she  may  be  spared  the  constant  sense  of  failure.  When 
the  symptoms  begin  to  improve,  the  child  may  be  allowed  to  leave  her 
bed  ;  and  games  which  involve  rhythmical  movement,  such  as  the  skipping- 
rope,  should  be  encouraged.  Benedikt  recommends  a  weak  constant  cur- 
rent along  the  spine.  The  child  should  stand  up  during  the  application, 
and  the  current  should  be  just  strong  enough  to  be  distinctly  felt. 

With  regard  to  drugs,  the  whole  pharmacopoeia  has  been  ransacked  for 
remedies  for  this  complaint.  The  disorder  has  been  attacked  with  anti- 
rheumatic remedies,  on  account  of  its  connection  with  rheumatism  ;  with 
iron,  cod-liver  oil,  and  tonics  generally,  on  account  of  the  weakness  and 
pallor  with  which  it  is  usually  associated  ;  with  phosphorus  and  other 
nervine  tonics  and  stimulants,  to  strengthen  the  nervous  system  ;  and  with 
the  whole  long  Ust  of  antispasmodics,  sedatives,  and  narcotics,  to  reduce 
nervous  excitement.  Where  there  is  great  ansemia  iron  is  very  useful,  and 
should  be  always  given.  In  these  cases,  too,  alcohol  is  of  great  service, 
and  the  child  should  take  a  wine-glassful  of  sound  claret,  diluted  with  an 
equal  quantity  of  water,  with  her  dimier.  Of  all  the  dJrugs  which  have 
been  recommended  as  specifics  in  this  complaint  the  only  one  from  which 
I  have  ever  seen  any  decided  benefit  has  been  arsenic,  and  with  this  only 
20 


306  DISEASE   ITn"   CHILDKEIs^. 

in  large  doses.  Cliikli-en  bear  arsenic  well.  I  have  been  in  tlie  habit  of 
prescribing  for  a  child  of  five  or  sis  years  of  age  ten  drops  of  Fowler's 
solution  of  arsenic,  dii-ectly  after  meals,  three  times  a  day.  In  this  dose  it 
is  rarely  found  to  disagree.  If  the  child  complain  of  discomfort  at  the 
epigastrium,  and  vomit  a  short  time  after  taking  the  remedy-^and  these 
are  the  only  unpleasant  symptoms  I  have  knoM'n  the  medicine  to  produce — 
it  can  be  given  for  a  time  twice  a  day  or  in  smaller  doses.  In  eveiy  case 
the  dose  should  be  as  large  a  one  as  can  be  borne  without  discomfort,  and 
given  thus  immediate  benefit  vrill  usually  ensue.  In  cases  where  arsenic 
is  iU  borne  by  the  stomach,  or  where  it  has  been  given  without  producing 
benefit,  the  ditig  may  be  administered  hypodermically.  Dr.  W.  A. 
Hammond,  of  New  York,  speaks  in  high  praise  of  this  manner  of  treating 
the  disease,  and  states  that  thus  administered  the  remedy  can  be  tolerated 
by  the  system  in  doses  considerably  larger  than  if  it  were  given  by  the 
mouth.  Dr.  Hammond  dii-ects  that  the  injection  should  be  made  slowly 
at  a  spot  where  the  skin  is  loose,  such  as  the  front  of  the  forearm  ;  that 
care  should  be  taken  to  conduct  the  fluid  into  the  subcutaneous  tissue  and 
not  into  the  skin  or  rmderlying  muscles  ;  and  that  Fowler's  solution  should 
be  used  diluted  with  an  equal  proportion  of  glycerine.  The  injection 
should  be  made  once  in  the  twenty-four  houi's,  beginning  with  ten  or 
twelve  drops  of  the  solution,  and  increasing  the  c^uantity  by  one  drop  each 
day. 

Almost  every  writer  on  this  subject  has  his  favourite  remedy.  Trousseau 
advocates  the  claims  of  moi-phia  and  strychnia  ;  Sir  Thomas  Watson  speaks 
in  high  praise  of  tui-pentine.  Svilphate  of  zinc  is  said  to  be  a  specific  by 
some  ;  others  prefer  bromide  of  potassium  or  chloral.  "Without  going 
thi'ough  the  list  of  drugs  specially  recommended,  it  may  be  suf&cient  to 
say  that  it  is  now  generally  held  that  the  bromides  are  most  useful  in  cases 
where  the  movements  are  violent  and  exhausting,  especially  if  there  be  any 
reason  to  suspect  ovarian  excitement ;  that  zinc  should  be  prefeiTed  for 
florid  children  and  the  more  acute  cases,  iron  for  the  paUid  subjects 
weakened  by  chronic  illness,  and  that  arsenic  given  by  the  mou'cn  effects 
its  most  rapid  cures  in  the  simjDler  forms  of  the  disease  where  the  muscular 
disturbance  is  not  extreme.  In  cases  of  acute  chorea  dependeni  upon 
meningitis  or  medullary  congestion  or  inflammation,  and  accompanied  by  a 
high  temperatiu'e.  Dr.  Jacoby  recommends  the  hquid  extract  of  ergot, 
given  in  half-drachm  doses  to  a  chUd  five  years  of  age,  thi-ee  or  four  times 
a  day,  and  continued  for  many  weeks  in  succession. 

In  very  bad  cases,  where  the  movements  ai'e  violent  and  incessant,  where 
the  child  cannot  sleep,  and  takes  food  with  the  utmost  difficulty,  the  best 
plan  is  to  put  the  patient  under  chloroform  at  stated  intervals  and  feed 
her  through  an  elastic  catheter  passed  dovm  the  gullet.  In  such  cases  a 
sufficient  quantity  of  stimulant  should  be  supj)hed  with  each  meal.  At 
night-time;  in  order  to  iasui-e  sleep,  a  full  dose  of  moi-phia  should  be  given 
hypodermically.  Much  benefit  is  sometimes  derived  from  Jaccould's  plan 
of  spraying  with  ether  the  whole  length  of  the  spine  t-oice  a  day.  Dr. 
Anstie  records  the  case  of  a  boy,  aged  six  years,  who  had  been  reduced  by 
the  violence  of  the  disease  into  an  almost  hopeless  condition.  At  length 
the  ether  spray  was  begun.  The  boy  at  once  began  to  improve,  and  in  a 
fortnight  the  disease  was  at  an  end. 

Obstinate  cases  of  chorea  may  be  sometimes  cured  by  the  plan  originated 
by  Dr.  Weir  INIitchell  and  ably  practised  by  Dr.  Playfair  in  cases  of 
aggravated  hysteria  in  women.  The  plan  consists  in  vigorous  shampooing 
or  "massage"  of  the  muscles,  so  as  to  excite  excessive  musculai' waste,  and 


CHOEEA — TEEATMENT.  307 

in  supplying  tlie  waste  so  induced  by  regular  and  excessive  feeding.  The 
shampooing  must  be  carried  out  energetically.  It  consists  in  kneading 
the  muscles  and  making  passive  movements  of  the  joints.  This  should  be 
done  several  times  daily  for  half  an  hour  on  each  occasion.  At  the  same 
time  the  patient  is  fed  with  large  quantities  of  milk,  meat,  eggs,  and  other 
nourishing  food.  By  this  means  all  the  more  violent  movements  are 
quickly  controlled,  the  extremities  become  warm,  the  child  sleeps  soundly 
and  rapidly  puts  on  flesh. 

In  every  case  where  the  movements  are  violent  care  should  be  taken 
that  the  patient  receives  no  injury  from  knocking  or  bruising  or  chafing 
the  skin.  The  sides  of  the  cot  should  be  padded  ;  and  the  child  should 
be  confined  to  the  bed  by  a  folded  sheet  passed  over  the  chest  and  tied 
underneath  the  cot. 

When  the  disease  has  passed  off,  means  must  be  taken  to  discipline  the 
mind  by  a  judicious  system  of  education,  both  moral  and  intellectual,  and 
the  child  should  be  encouraged  to  take  part  in  active  games  and  out-of- 
door  exercises.  A  change  to  the  sea-side  is  often  useful  to  complete  the 
cure. 


CHAPTEE  YIII. 

IDIOPATHIC  TETANUS. 

Tetanus  or  lock-jaw,  as  it  attacks  new-born  children,  is  a  disease  of  which 
in  England  we  know  little  by  actual  experience.  A  few  cases  are,  however, 
seen  from  time  to  time,  and  it  is  not  unlikely  that  but  for  the  tender  age 
of  the  infant  attacked,  and  the  rapidity  with  which  the  disease  hurries  to  a 
close,  more  examples  of  the  malady  might  come  under  observation.  Cer- 
tainly, at  the  east  end  of  London,  in  the  Iiish  quarters,  where  squalor  and 
poverty  are  often  extreme,  it  is  strangely  common  to  hear  of  several  infants 
of  a  family  having  died  a  few  days  after  birth  from  "  convulsions."  Such 
cases  have  probably  come  under  the  notice  of  no  more  experienced  obser- 
ver than  an  ordinary  midwife,  and  it  is  quite  possible  that  many  cases  of 
infantile  tetanus  may  thus  escape  recognition. 

The  disease  consists  in  an  intense  irritability  of  the  spinal  cord  and  the 
motor  nerves  which  proceed  from  it,  throwing  the  whole  body  into  violent 
tonic  spasms.  Infantile  tetanus  runs  a  very  acute  course  and  generally 
ends  in  death.  It  is  common  in  the  West  Indian  islands,  in  South  America, 
and  in  the  southern  portion  of  the  United  States.  In  these  warm  climates 
it  attacks  by  preference  the  new-born  children  of  the  negro  population. 
It  is  also  occasionally  found  in  more  temperate  zones.  The  island  of  St. 
Kilda  in  the  Hebrides  has  long  been  notorious  for  its  enormdus  infant  mor- 
tahty  from  this  cause,  and  sometimes  in  other  parts  of  Europe  the  disease 
occurs  sporadically  or  even  in  occasional  epidemics. 

Causation. — Much  speculation  has  been  bestowed  upon  the  etiology  of 
the  disease  as  it  occurs  in  new-born  infants,  and  many  theories  have  been 
devised  to  account  for  it.  The  fact  that  the  symptoms  appear  within  a  few 
days  of  birth  seems  to  point  to  some  traumatic  cause  for  the  illness,  and 
suspicion  naturally  f eU  at  once  upon  the  remnant  of  the  newly  divided  um- 
bihcal  cord.  Hence  the  disease  has  been  ascribed  to  phlebitis  of  the  um- 
bilical veins.  The  explanation  has,  however,  been  proved  to  be  erroneous. 
Dr.  Mildner,  of  Prague,  has  collected  forty-six  cases  of  inflammation  of  the 
umbilical  vessels  which  ended  fatally.  In  only  five  of  these  did  convulsions 
form  part  of  the  symptoms,  and  in  no  instance  did  the  con^odsions  bear 
any  resemblance  to  those  characteristic  of  tetanus.  Again,  phlebitis  of  the 
umbilical  veins,  although  an  occasional  accomj)animent  of  inf  antUe  tetanus,, 
is  more  often  absent  than  present.  Inflammation,  then,  cannot  be  a 
cause  of  the  disease,  but  still  it  does  not  follow  that  tetanus  is  independent 
of  the  condition  of  the  cord.  Even  in  the  adult  inflammation  of  a  wound 
is  not  essential  to  the  production  of  traumatic  lockjaw,  for  the  malady  has 
been  known  to  occur  in  cases  where  the  wound  had  undergone  healthy 
cicatrisation.  _        ' 

Mechanical  causes  for  the  disease,  such  as  blows  or  accidental  injuries, 
and  the  use  of  too  hot  water  for  the  bath,  have  been  suggested  by  some 
authors.    An  eminent  American  writer  has  attributed  the  disorder  to  press- 


TETANUS — CAUSATION- — MORBID   ANATOMY.  309 

ure  on  the  medulla  oblongata  and  its  nerves,  through  displacement  oc- 
curring either  during  labour,  or  after  birth  from  the  child  being  allowed  to 
lie  for  days  together  -with  the  back  of  his  head  upon  a  pillow. 

Although  the  disease  may  arise  from  these  or  other  traumatic  causes, 
it  seems  likely  that  an  explanation  of  the  phenomena  is  to  be  found  in 
general  rather  than  in  local  agencies.  The  influence  of  sudden  changes  of 
temperature  in  producing  tetanus  hardly  admits  of  doubt.  In  all  countries 
where  the  complaint  is  prevalent  there  are  rapid  alternations  of  tempera- 
ture, the  heat  of  the  day  passing  suddenly  into  the  cool  of  the  evening.  On 
this  account  interruption  to  the  functions  of  the  skin  has  been  suggested 
as  the  immediate  cause  of  the  disease.  In  the  same  way  chilling  of  the 
surface  by  exposure  to  cold  and  wet  has  been  said  to  be  capable  of  exciting 
the  tetanic  convulsion.  Of  all  causes,  however,  to  which  the  disease  has 
been  attributed  foul  air  generated  by  filth  and  imperfect  ventilation  is, 
perhaps,  one  of  the  best  established.  The  often  quoted  case  of  the  Dublin 
Lying-in-Asylum  seems  to  prove  this  conclusively.  Before  1772  nearly  one 
in  every  six  of  the  children  born  alive  in  the  asylum  died,  and  the  cause  of 
death  was  almost  invariably  tetanus.  In  that  year  Dr.  Joseph  Clarke  intro- 
duced a  complete  system  of  ventilation  into  the  hospital.  The  consequence 
was  that  the  mortality  immediately  fell  to  one  in  nineteen.  Later,  the 
proportion  of  deaths  was  still  further  reduced  to  one  in  fifty-eight,  and  of 
those  who  died  little  more  than  a  ninth  died  from  this  disease. 

In  St.  Kilda  the  high  rate  of  mortality  may  with  much  probabihty  be 
attributed  to  a  similar  absence  of  fresh  air  and  cleanliness  in  their  homes. 
That  some  cause  is  there  in  existence  which  does  not  obtain  in  the  neigh- 
bouring islands  is  evident,  for  children  born  of  natives  of  St.  Kilda  out  of 
the  island  escape  the  disease,  and  hence  the  occurrence  of  the  affection  can- 
not be  attributed  to  intermarriage  or  any  hereditary  influence. 

Dr.  Holland  in  his  "  Summary  of  the  Diseases  of  the  Icelanders,"  re- 
cords the  frequency  of  trismus  nascentium  in  the  island  of  Heimaey,  one 
of  a  group  situated  on  the  southern  coast  of  Iceland.  He  states  that  almost 
every  infant  born  on  the  island  died  of  this  disease,  and  that  consequently 
the  population  was  supported  almost  entirely  by  immigration  from  the 
mainland.  It  appears  that  there  was  no  vegetable  food  upon  the  island,  and 
that  the  natives  lived  principally  upon  sea-buxls  which  they  salted  and 
barrelled.  Dr.  Holland  attributes  the  disease  to  ii'ritation  of  the  bowels 
excited  by  the  practice  of  feeding  the  infants  shortly  after  birth  upon  a 
strong  and  oily  animal  food.  He  foi'tifies  his  opinion  by  the  fact  that  at 
St.  Kilda,  where  the  diet  and  mode  of  life  of  the  natives  resembled  those 
prevailing  at  Heimaey,  the  disease  was  equally  prevalent  and  equally  fatal. 

Tetanus  is  occasionally  seen  in  older  children,  as  a  consequence  of  some 
cut,  or  bruise,  or  other  injury,  as  is  the  case  in  the  adult.  Sometimes  it 
is  idiopathic,  and  is  then  probably  rheumatic  in  its  nature. 

Morbid  Anatomy. — Extreme  injection  of  the  small  vessels  of  the  spinal 
cord  and  its  membranes,  with  extravasation  of  blood  into  the  cellular  tis- 
sue around  the  theca,  and  also  into  the  cavity  of  the  spinal  arachnoid,  has 
usually  been  described  as  a  common  consequence  of  infantile  tetanus.  In 
a  case  which  died  in  the  East  London  Children's  Hospital,  under  the  care 
of  my  colleague,  Mr.  Parker,  there  was  a  striking  absence  of  congestion  of 
the  cord  and  its  membranes.  On  opening  the  spinal  canal  the  loose  con- 
nective tissue  around  the  cord  was  found  to  be  ecchymosed  in  patches 
from  the  middle  to  the  lower  end  of  the  dorsal  portion  of  the  coi'd.  On 
opening  the  spinal  dui-a  mater,  the  pia  mater  did  not  present  any  unusual 
appearance.     It  did  not  appear  abnormally  congested.     The  cord  itself 


310  DISEASE  IN   CHILDREN". 

was  firm  to  the  touch.  On  cutting  into  it,  the  gray  matter  was  clearly 
mapped  out  by  its  pink  colour  when  compared  with  the  white  substance. 
There  were  no  extravasations  into  its  substance  at  any  point. 

In  some  cases  in  adults  Eokitansky  and  Demme  have  observed  a  de- 
velopment of  connective  tissue  in  the  spinal  cord. 

Symptoms. — The  disease  generally  begins  on  the  third,  foiu'th,  or  fifth 
day  after  birth.  It  is  rarely  delayed  longer  than  the  tenth.  The  first 
symptom  mentioned  by  the  mother  is  usually  that  the  child  cannot  take 
the  breast,  or  that  if  he  attempt  to  do  so  he  quickly  abandons  the  nipple. 
Sometimes  the  milk  is  noticed  to  run  out  of  his  mouth,  as  if  he  had  a  diffi- 
culty in  swallowing  it.  Soon  the  jaws  become  stiff  and  the  face  has  a 
rigid,  pinched  look.  The  spasms  extend  from  the  muscles  of  the  jaw  to 
the  neck,  the  back,  and  finally  the  hmbs,  so  that  in  a  short  time  a  general 
muscular  rigidity  is  obseiwed,  which  comes  on  in  paroxysms,  lasts  for  a 
variable  time,  and  then  remits  to  return  after  a  short  interval.  The  infant 
may  utter  a  pitiful  whimper  when  the  paroxysm  begins,  but  at  once  the 
muscles  become  stiff  and  hard,  the  eyes  are  tightly  closed,  the  jaws  are 
set,  with  the  mouth  a  little  open,  the  head  is  drawn  backwards,  the  hands 
are  clenched,  and  the  feet  are  flexed  upon  the  ankles.  Sometimes  there  is 
ojDisthotonos.  If  the  paroxysm  is  short  respiration  may  be  suspended 
and  the  face  become  dusky,  but  in  the  longer  attacks  breathing  generally 
continues.  Each  attack  lasts  from  a  few  seconds  to  haK  a  minute,  and 
the  intervals  between  them  may  be  a  few  minutes  or  longer.  In  the  inter- 
val the  spasm  does  not  completely  relax,  there  is  some  lividity  of  the  face, 
the  head  often  remains  more  or  less  retracted,  the  hands  continue  clenched 
and  the  thumbs  are  twisted  inwards.  At  this  time  a  touch  will  frequently 
excite  the  recurrence  of  the  paroxysm.  If  milk  is  put  into  the  mouth  the 
child  may  be  unable  to  swallow  it,  or  if  he  attempt  to  do  so  the  effort 
may  bring  on  a  return  of  the  spasms.  The  want  of  nourishment  and  the 
exhaustion  induced  by  the  convulsions  cause  rapid  emaciation.  In  most 
cases  the  interval  between  the  attacks  becomes  shorter  and  shorter,  and 
the  child  sinks  exhausted,  or  dies  asphyxiated  from  spasm  of  the  muscles 
of  respiration.  From  the  very  beginning  of  the  attack  the  child  ceases 
entirely  to  cry.  Occasionally  he  may  whimper  faintly,  but  a  loud  cry  is 
never  heard.  The  temperature  usually  varies  from  99.5°  to  101°  or  102°. 
It  may  fall  below  the  normal  level  before  death,  or  may  rise  to  104°  or 
105°.  In  a  case  recorded  by  Ingersley  the  temperature  in  some  of  the 
attacks  reached  107°.  In  this  case  albumen  and  casts  were  found  in  the 
urine,  and  the  kidneys,  after  death,  showed  marks  of  acute  nephritis,  with 
extravasations  of  blood. 

Death  usually  occurs  at  the  end  of  a  day  or  two.  The  infant  seldom- 
recovers  if  the  paroxysms  have  appeared  before  the  third  day  after  bii'th. 
If  the  child  live  six  days  after  the  appearance  of  the  first  symptoms,  the 
case  may  terminate  favourably. 

In  Mr.  Parker's  case,  before  refeiTcd  to,  the  arms  were  noticed  to  ba 
stiff  immediately  after  birth,  and  they  could  not  be  flexed.  For  a  day  or 
two  the  child  sucked  without  difficulty,  then  the  milk  was  observed  to 
run  out  of  his  mouth.  On  the  fifth  day,  soon  after  the  navel-string  feU  off, 
he  began  to  have  slight  spasms.  If  the  nipple  was  put  into  his  mouth  the 
spasms  were  immediately  excited.  On  admission  on  the  fifth  day  the 
cranial  bones  presented  no  abnormality.  The  child  lay  with  the  eyehds 
screwed  up.  Eis  mouth  was  not  quite  closed,  but  any  attempt  to  open  it 
wider  brought  on  a  tetanic  spasm.  There  was  no  risus  sardonicus.  When 
stripped,  the  child's  body  was  seen  to  be  covered  with  hsemorrhagic  flea- 


TETANUS — SYMPTOMS.  311 

bites.  The  umbilictis  was  slightly  red  and  inflamed,  but  there  was  no  dis- 
charge from  it.  There  were  no  marks  of  violence,  nor  any  sores  of  any 
kind  about  the  body.  The  limbs  were  rigid  and  outstretched,  the  legs 
rather  less  so  than  the  arms ;  the  hands  were  clenched.  The  abdominal 
and  thoracic  walls  were  also  rigid  during  the  spasm,  but  they  partially  re- 
laxed after  the  spasm  had  passed  off.  The  limbs  never  quite  relaxed  dur- 
ing the  intervals.  The  spasms  were  of  short  duration  (a  quarter  to  half  a 
minute),  and  affected  the  whole  body  at  once.  They  recurred  very  rapidly, 
and  the  slightest  touch  sufficed  to  bring  them  on.  Respiration  was  quite 
arrested  during  the  paroxysm.  There  was  no  opisthotonos.  The  temper- 
ature, taken  in  the  rectum,  was  103.8°. 

The  case  was  treated  with  the  calabar  bean  extract,  of  which  one-sixth 
of  a  grain  was  given  every  half  hour  by  the  mouth  ;  but  as  the  infant  was 
unable  to  swallow,  probably  very  little  of  the  remedy  was  really  introduced 
into  the  system.  Still,  possibty  some  was  absorbed,  for  after  several  doses 
the  child  opened  his  eyes  and  was  able  to  swallow  milk.  He  was  then 
placed  in  a  warm  bath  and  the  bean  extract  was  given  every  two  hours. 
The  infant  had  some  spasms  during  the  bath,  and  a  few  others  shortly 
afterwards,  but  in  the  course  of  an  hour  they  ceased  entirely  and  the 
child  seemed  to  be  going  on  well,  when  suddenly  a  violent  paroxysm  came 
on  and  he  died  asphyxiated.  The  temperature  varied,  after  the  first,  be- 
tween 100.8°  and  102.4°.  The  child  hved  only  about  sixteen  hours  after 
his  admission  into  the  hospital. 

In  fatal  cases  the  duration  of  the  illness  is  usually  short.  Sometimes 
the  infant  dies  in  a  few  hours,  and  in  the  majority  of  cases  all  is  over  be- 
fore the  end  of  the  second  day.  More  rarely  the  child  makes  a  better 
struggle  for  life,  and  only  succumbs  on  the  eighth  or  ninth  day.  When 
the  disease  takes  a  mild  form  from  the  beginning  it  may  terminate  favour- 
ably after  a  more  or  less  serious  illness  of  two  or  three  weeks. 

"When  tetanus  attacks  children  after  the  age  of  infancy,  the  symptoms 
are  similar  to  those  which  are  seen  in  the  adult.  They  are  well  illustrated 
by  the  following  case  of  idiopathic  tetanus  which  was  under  my  care  in 
the  East  London  Children's  Hospital. 

A  boy,  aged  ten  years,  complained  one  day  on  returning  from  school 
of  chilliness,  and  shivered.  For  the  next  three  days  he  seemed  poorly  and 
complained  constantly  of  feeling  cold.  On  the  fourth  day,  in  the  evening, 
his  neck  became  stiff,  and  the  stiffness  extended  to  between  the  shoulders 
so  that  he  held  his  head  backwards.  On  the  following  day  (the  fifth)  he 
began  to  "  get  straight "  from  the  hips  upwards,  and  the  stiffness  soon  ex- 
tended to  the  feet.  Although  very  ill,  he  would  sit  up  in  a  chair  during 
the  day,  and  on  one  occasion,  on  being  raised  to  his  feet  at  his  own  re- 
quest, he  became  perfectly  stiff  so  that  his  mother  could  not  bend  him  or 
replace  him  in  his  chair.  After  about  a  minute  the  rigidity  subsided  and 
he  resumed  his  seat.  He  complained  of  no  pain  except  from  his  tongue, 
which  he  often  bit  in  these  attacks.  After  this  the  stiffness  returned  when- 
ever he  moved.  His  mind  was  quite  clear,  but  except  for  asking  for  what 
he  wanted  he  did  not  talk.     The  bowels  were  much  confined. 

The  boy  was  admitted  into  the  hospital  on  November  12th,  two  weeks 
after  his  complaint  of  chilliness.  It  was  noted  that  he  had  no  marks  of 
external  injury.  His  face  was  drawn  from  contraction  of  the  muscles,  and 
there  was  risus  sardonicus.  Occasionally  his  body  became  quite  stiff,  his 
arms  and  legs  rigid  and  extended,  the  abdominal  muscles  hard  and  the 
muscles  of  the  nucha  contracted.  There  was  no  opisthotonos.  These  at- 
tacks generally  came  on  at  night.     On  the  night  of  November  14th  he  had 


312  DISEASE   IN   CHILDEEIST. 

niBe  of  the  spasms,  on  the  IStli,  ten.  He  often  bit  his  tongue.  During 
the  first  few  days  his  pulse  "was  80  ;  temperature,  99-101°  ;  respii-ation, 
20-21.     The  lungs  and  heart  were  healthy. 

On  the  16th,  at  6  p.m.,  he  began  to  take  calabar  bean  extract,  one-sixth 
of  a  gTain  every  half  houi\  This  reduced  his  pulse  in  a  few  horu's  to  54, 
On  the  17th  it  was  noticed  :  "  Abdominal  muscles  feel  hard,  and  there  is 
much  rigidity  of  the  back  of  the  neck.  No  stifihess  of  joints  of  arms  or 
legs.  Can  only  partiaUy  open  mouth,  when  he  does  so  the  muscles  under 
the  chin  become  very  stiii,  but  are  painless.  Keeps  his  eyes  closed  although 
light  is  not  distressing  to  them.  Cheeks  and  eyehds  rather  red.  His  face 
has  a  pecuhar  drawn  expression  ;  nostrils  widely  open.  Tongue  sore  from 
biting.  Has  no  difficulty  in  swallowing.  When  asleep,  the  muscles  are 
much  less  rigid  than  when  he  is  awake,  unless  during  the  actual  spasm. 
Temperature  at  9  a.m.,  98.2°  ;  pulse,  72,  small  and  compressible,  regular 
in  force  but  not  in  rhythm  ;  respiration,  22." 

During  the  whole  of  the  17tli  the  boy  had  only  one  i^aroxysm.  In  the 
course  of  the  following  night  he  had  three  attacks.  At  10  p.m.  on  this 
night  (the  17th),  his  pulse  being  only  18,  the  medicine  was  ordered  to  be 
given  every  houi-  instead  of  half  hour.  After  this  the  spasms  became 
fewer  and  less  severe  and  the  rigidity  of  the  muscles  gradually  relaxed. 
The  spasms  still  continued  to  occiu'  at  times  durmg  sleep,  but  they  usu- 
ally subsided  at  once  when  the  child  was  roused.  The  bean  extract  was 
stopped  on  the  25th.  His  imjDrovement  continued  and  the  patient  was 
pronounced  convalescent  on  December  12th.  The  last  muscles  to  become 
completely  relaxed  were  those  of  the  abdominal  wall. 

Diagnosis. — Infantile  tetanus  is  a  disease  which  it  is  not  easy  to  mistake. 
Yioleut  paroxysms  of  tonic  rigidity  in  which  the  jaws  are  set,  the  chest  is 
fixed,  the  muscles  generally  are  stiff  and  hai'd,  and  the  face  becomes  dusky 
and  di'awn — these  seizures  occuning  without  twitching  or  sign  of  clonic 
spasm,  and  followed  by  intervals  of  only  partial  relaxation,  ai-e  xery  char- 
acteristic. 

In  older  children  it  is  imiDortant  to  distingiiish  between  tetanus  and 
the  symptoms  of  strychnia  poisoning.  According  to  Sii'  Eobert  Christison, 
tetanus  does  not  kill  so  quickly  as  a  poisonous  dose  of  strychnia.  Moreover, 
in  tetanus  the  symptoms  become  developed  gTadually  ;  in  stiychnia  poi- 
soning the  convulsions  very  rapidly  become  general,  and  a  perfect  fit  is  de- 
veloped in  an  hour,  or  even  more  quickly  still.  If  strychnia  have  been 
given  in  carefully  graduated  doses,  the  distinction  is  less  easy,  but  even 
in  these  cases  there  are  very  decided  difierences.  Tetanus  begins  gradu- 
ally and  always  runs  a  continuous  cotu'se.  Su'  B.  Brodie  declared  that  he 
had  never  known  a  case  of  tetanus  to  begin,  then  subside,  and  then  begin 
again  in  twenty-four  hours.  This  continuity  of  symptoms  would  be  diffi- 
cult to  simulate  even  by  the  most  carefuUy  graduated  doses  of  the  poison. 
Again,  in  strychnia  ^^oisoning  the  upper  extremities  are  affected  early  ;  in 
tetanus  they  are  imphcated  late,  and  the  fingers  last  of  all.  The  facies, 
too,  of  tetanus  is  very  pecuhar.  The  forehead  is  wrinkled  perpendicularly 
and  transversely,  the  eyebrows  being  di-awn  towards  one  another  in  a  very 
remarkable  manner.  The  eyes  are  not  fully  opened;  there  is  a  "peering 
look "  which  is  very  characteristic,  and  after  a  time  the  eyeball  becomes 
painfuUy  sunken  from  tetanic  contraction  of  its  muscles.  In  strychnia 
poisoning  the  eyehds  are  ^videly  opened  and  the  ej'eballs  protrude. 

Prognosis.— So  few  children  recover  from  this  disease  that  the  prog- 
nosis is  always  very  unfavourable.  Dr.  Lewis  Smith  has  collected  forty 
cases,  of  which  thh-ty-two  died  and  eight  recovered.     This  is  a  large  pro- 


TETANUS — DIAGJSrOSIS — TEEATMENT.  313 

portion  of  recoveries,  but  statistics  gathered  from  published  cases  alone 
probably  represent  but  feebly  the  fatal  nature  of  the  illness  ;  for  in  so 
mortal  a  disease  it  is  likely  that  maiiy  more  successes  than  failui'es  would 
be  jDlaced  upon  record.  Early  occurrence  of  the  symptoms  after  birth, 
great  violence  of  the  spasms,  shortness  of  the  period  of  remission,  and 
a  very  high  temperature  should  excite  the  gravest  apprehensions.  The 
most  favourable  cases  are  those  in  which  the  disease  appears  after  the 
first  week  has  passed.  The  symptoms  are  then  as  a  rule  less  severe,  and 
sometimes  deglutition  is  unaffected.  The  ability  or  inability  of  the  child 
to  swallow  is  an  important  element  in  the  case.  If  he  still  continue  capa- 
ble of  swallowing  milk  from  a  sjjoon,  we  are  justified  in  entertaining  some 
hope  of  ultimate  recovery. 

In  an  older  child  the  prospect  is  more  favourable  if  the  disease  be 
idiopathic  than  if  it  follow  upon  an  injury  ;  but  in  any  case  we  cannot 
look  forward  without  serious  anxiety  to  the  termination  of  his  illness. 

Treatment. — In  every  case  of  infantile  tetanus  our  first  care  should  be 
to  remove  all  sources  of  irritation,  whether  internal  or  external.  The 
infant  must  be  kept  quiet  in  a  room  carefully  darkened,  and  the  bowels 
should  be  relieved  by  a  good  dose  of  castor-oil,  or  if  he  cannot  swaUow,  by 
a  copious  enema.  Next,  the  rapid  emaciation  must  be  counteracted  by 
regular  feeding.  The  gTeat  obstacle  to  efficient  nutrition  is  the  spasm  of 
the  muscles  of  deglutition  which  makes  swallowing  so  often  impossible. 
Infants  cannot  be  nourished  per  rectum.  It  is  therefore  advisable  to  put 
the  child  under  chloroform  at  regular  intervals  and  administer  his  mother's 
milk,  if  it  can  be  obtained,  or  if  not,  asses'  milk,  cow's  milk  and  barley- 
water  (equal  parts),  or  other  suitable  food,  through  an  elastic  catheter 
passed  down  the  gullet.  In  this  way  three  or  four  ounces  of  food  can  be 
administered  every  three  hours  ;  and  with  each  quantity  it  is  advisable  to 
mix  fifteen  or  twenty  drops  of  sound  brandy. 

The  third  indication  is  to  control  the  spasms.  For  this  pui'pose  some 
form  of  sedative  must  be  resorted  to.  Opium,  alone  or  combined  with 
anti-spasmodics  such  as  sulphate  of  zinc  or  assafoetida,  Indian  hemp,  and 
belladonna  or  its  alkaloid  have  l^een  all  employed.  Whatever  form  be 
used,  it  should  be  given  with  the  food  through  the  catheter  or  hypoder- 
micaUy  in  frequent  small  doses.  Chloroform  checks  the  paroxysms  for  a 
time,  but  they  return  when  the  effects  of  the  anaesthetic  have  passed 
away.  Good  results  have  been  obtained  from  the  extract  of  calabar  bean. 
In  Mr.  Parker's  case,  previously  narrated,  even  the  small  quantity  of  the 
remedy  absorbed  seemed  certainly  to  prolong  the  intervals  of  remission, 
although  the  seizures  when  they  occurred  were  not  diminished  in  severity. 
The  drug  should  be  administered  hypodermically  if  the  child  cannot  swal- 
low. The  dose  should  be  one-twelfth  of  a  grain  by  the  mouth,  or  one- 
twentieth  by  subcutaneous  injection,  every  hour  or  two  hours,  watching 
the  effect.  It  is  advisable  to  produce  some  decided  effect  upon  the  heart 
^nd  lungs,  reducing  the  rapidity  of  the  pulse  and  the  breathing,  if  any 
good  result  is  to  be  hoped  for. 

Of  all  the  drugs  which  have  been  recommended  for  this  disease  the 
most  favoiu'able  results  appear  to  have  been  obtained  from  chloral.  Dr. 
Widerhofen  claims  six  recoveries  in  twelve  patients  by  the  use  of  this 
.agent,  but  the  only  case  referred  to  in  the  short  extract  from  his  lecture 
which  appeared  in  the  Lancet,  was  not  of  a  very  severe  character,  as  the 
symptoms  came  on  late  and  deglutition  was  not  interfered  with.  In  a  case 
which  was  under  my  care  in  the  East  London  Children's  Hospital  this 
remedy  was  employed,  and  although  the  baby  died  the  effect  of  the  drug 


314  DISEASE   I]Sr   CHILDKEN. 

upon  the  spasms  was  decidedly  encouraging.  The  difficulty  appears  to  be- 
to  regidate  the  dose  accurately  so  as  to  dominate  the  seizures  without  pro- 
ducing too  serious  a  depression.  For  the  notes  of  the  case  I  am  indebted 
to  jMr.  J.  Scott  Battams  the  Resident  Medical  Officer,  who  watched  the 
child  with  great  attention. 

A  httle  boy,  four  days  old,  of  healthy  Irish  parentage,  was  admitted 
October  18,  1881.  The  father  and  mother  with  three  other  children  be- 
sides the  patient  occupied  one  room,  which  was  said  to  be  clean  and  large. 
The  bed  in  which  the  child  lay  with  his  mother  was  placed  in  a  strong 
draught,  of  which  the  woman  had  constantly  complained.  The  child  was- 
born  to  all  apjDearance  healthy,  and  took  the  breast  well  until  the  day  be- 
fore admission,  when  he  was  noticed  for  the  first  time  to  be  unable  to 
suck.  That  night  the  infant  slept  badly,  crying  and  drawing  up  his  legs. 
The  cry  was,  however,  strong  even  on  the  morning  of  admission. 

When  first  seen  (October  18th,  noon)  the  baby  was  dirty  but  seemed  weU. 
noui'ished  ;  navel  aj)parently  healthy  ;  cranial  bones  normal.  Every  five 
minutes  spasms  occuiTed  of  moderate  severity  ;  they  did  not  arrest  the 
breathing.  In  the  spasms  the  legs  were  drawn  up  rigidly,  the  forearms 
were  flexed,  the  fingers  were  stretched  out  and  widely  separated,  the  lips 
pouted  a  httle  and  there  was  risus  sardonicus,  the  jaw  was  fixed  and  the 
head  was  slightly  retracted.  An  attempt  to  open  the  eyes  or  mouth  aggra- 
vated the  spasms.  At  this  time  the  person  who  brought  the  child  refused 
to  leave  him  without  the  consent  of  the  mother.  At  6  p.m.,  however,  he 
was  brought  back  and  admitted.  He  had  taken  no  food  since  11  p.m.  of 
the  previous  evening.  The  spasms  had  continued  all  the  afternoon  and 
were  more  severe  than  at  first.  The  bowels  were  relieved  by  enema  of  a 
large  quantity  of  curd,  and  the  child  was  put  into  bed  with  an  ice-bag  to  the 
spine.  Between  7  p.m.  and  midnight  three  enemata  of  milk,  containing, 
respectively,  four  grains,  six  grains,  and  six  grains  of  chloral,  w^ere  admin- 
istered. After  three  hours  the  ice-bag  was  removed.  At  midnight  the 
child  was  no  better.  As  he  remained  unable  to  swallow,  he  was  put  under 
chloroform,  and  three  ounces  of  his  mother's  milk  with  four  grains  of 
chloral  were  injected  through  a  catheter  passed  into  the  stomach.  This 
was  repeated  at  4.30  a.m.,  after  which  the  catheter  was  passed  without  dif- 
ficulty and  without  chloroform,  and  between  two  and  three  ormces  of  his 
mother's  milk  with  ten  drops  of  brandy  were  given  every  two  or  three 
hours.  During  this  time  the  convulsions  had  varied  in  intensity  as  well  as 
in  number.  They  were  manifestl}^  influenced  by  the  chloral,  so  that  from 
5  A.M.  (19th)  until  10  a.m.  he  slept  quietly. 

At  10  A.M.  (October  19th)  the  hmbs  were  quite  relaxed,  and  the  child's 
face  was  somewhat  dusky.  Verj'  little  aii-  seemed  to  be  entering  the  lungs. 
On  passing  the  catheter  into  the  stomach  veiy  httle  spasm  was  excited. 

At  2  P.M.  Mr.  Battams  was  sent  for,  as  the  infant  was  thought  to  be  dead.. 
On  making  artificial  respiratory  movements  the  child  gave  a  gasp.  From 
this  time  until  5  p.m.  he  continued  to  breathe  eight  times  per  minute. 
The  conjunctivae  were  insensible,  the  surface  was  cold,  but  there  was  less 
cyanosis.  Some  brandy  was  administered.  At  10  p.m.  his  condition  remained 
unaltered,  excejDt  that  the  respirations  were  now  reduced  to  four  per  min- 
ute.    No  more  spasms  had  occurred. 

On  October  20th,  at  2.30  a.m.,  the  child  was  again  thought  to  be  dead, 
but  artificial  respiration  revived  him  for  a  time  ;  he,  however,  finally  sank 
about  3  A.M. 

The  .temperature  was  98°  on  admission  (October  18th),  99°  at  9  p.m. 
On  the  19th  it  was  100.6°  at  midnight,  99.8°  at  2.15  p.m.,  94.8°  at  5.30 


TETANUS — TEEATMENT.  315 

P.M.,  95.8°  at  7.30  p.m.,  and  96°  at  10.30  p.m.  No  post-mortem  examination 
was  allowed. 

In  this  case  the  remedy  was,  no  doubt,  administered  too  energetically. 
It  would  have  been  better,  after  the  first  dose  or  two  of  the  chloral,  to 
have  given  the  drug  in  smaller  quantities,  even  if  it  had  to  be  repeated 
more  frequently.  Had  this  been  done,  the  result  might  have  been  differ- 
ent. I  have  been  unable  to  find  any  rule  by  which  the  administration  of 
the  remedy  may  be  regulated.  Whether  it  be  advisable  to  proceed  to 
actual  narcotism,  or  whether  it  is  preferable  to  stop  short  of  that  point, 
must  be  a  matter  for  individual  experience  to  acquire,  and  in  this  country 
such  experience  is  difficult  or  impossible  to  obtain.  Widerhofen  directs 
gr.  j.-ij.  by  the  mouth,  or  gr.  ij.-iv.  by  the  rectum,  to  be  given  "  at  the  time 
of  each  onset  of  convulsion."  This  direction  is  too  vague  to  be  useful  as 
a  guide  in  practice,  and  can  scarcely  be  intended  to  apply  to  a  case  such 
as  the  present,  where  the  intervals  of  remission  were  so  brief. 

Tobacco  and  woorara  have  also  been  recommended,  but  must  be  very 
dangerous  drugs  to  use  at  so  early  an  age,  even  when,  as  in  this  disease, 
there  is  such  a  remarkable  tolerance  of  sedatives.  External  applications 
are  sometimes  employed.  Warm  baths  and  cold  packing  have  both  their 
advocates.  In  Mr.  Parker's  case  the  warm  bath  seemed  to  have  a  decidedly 
unfavourable  effect  upon  the  infant. 


CHAPTEE  IX. 

CONGESTION   OF   THE  BRAIN. 

Congestion  of  the  brain  is  a  term  wliich  is  often  used  very  loosely,  and  is 
probably  applied  to  various  forms  of  illness.  Writers  who  have  dealt 
with  the  subject  of  disease  in  early  life  differ  curiously  in  the  importance 
they  attach  to  the  subject  of  cerebral  hypersemia,  some  attributing  to  it 
most  of  the  convulsive  diseases  to  which  young  children  are  liable  ;  others, 
as  Valleix,  asserting  that  this  pathological  condition  is  almost  unknown  in 
infancy. 

The  view  formerly  held  that  the  quantity  of  blood  circulating  within 
the  cranium  is  constant  and  cannot  be  influenced  by  altered  conditions  of 
the  body  generally,  has  now  been  proved  to  be  erroneous.  The  researches 
of  Kobin  and  of  His  have  shown  that  surrounding  the  cerebral  blood-ves- 
sels are  lymphatic  sheaths  which  communicate  with  the  lymphatics  of  the 
pia  mater,  and  are  several  times  the  size  of  the  blood-vessels  they  enclose. 
These  lymphatic  canals  contain  a  fluid  which  increases  or  diminishes  in 
quantity  according  to  the  varying  distention  of  the  blood-vessels,  and 
must  therefore  allow  of  great  variety  in  the  amount  of  fluid  circulating 
within  the  cranial  cavity.  There  is  no  doubt,  therefore,  that  hypersemia 
of  the  blood-vessels  can  take  place  ;  but  it  does  not  follow  because  evi- 
dences of  this  congestion  are  discovered  in  the  dead  body  that  it  was  the 
cause  of  the  symptoms  from  which  the  patient  had  suffered.  It  is  common 
in  cases  of  death  from  convulsions  to  find  engorgement  of  the  vessels  of 
the  brain  and  membranes,  but  this  engorgement  is  probably  as  often  a 
consequence  of  the  convulsion  as  a  cause  of  it.  Still,  every  physician 
practising  amongst  children  must  now  and  again  meet  with  cases  in  which 
he  finds  a  group  of  symptoms  suggestive  of  some  temporary  increase  of 
pressure  upon  the  brain.  These  symptoms  either  pass  off  after  a  time  and 
the  child  recovers,  or  they  increase,  the  patient  dies,  and  on  examination 
•of  the  skull  cavity  nothing  but  a  hypersemic  state  of  the  cerebral  vessels 
vsdth  an  effusion  of  serum  is  seen  to  account  for  the  illness.  These  symp- 
toms are  therefore  supposed  to  indicate  congestion  of  the  brain  ;  but  there 
is  probably  some  deeper  and  less  obvious  cause  of  the  impairment  of 
function,  for  although  this  pathological  condition  may  be  invariably  pres- 
ent, it  cannot  be  held  to  furnish  a  full  and  satisfactory  explanation  of  the 
phenomena. 

Causation. — Cerebral  congestion  may  occur  in  two  forms  :  An  active 
hypersemia  from  increased  flow  of  blood  into  the  brain,  and  a  passive  hy- 
persemia from  obstruction  to  the  return  of  blood  from  the  interior  of  the 
skull.  Many  different  causes  have  been  enumerated  as  giving  rise  to  the 
condition,  but  it  is  difiicult  to  accept  all  of  them  as  determining  agents  in 
the  production  of  cerebral  congestion.  Dentition  is  usually  said  to  be  a 
cause  of  vascular  engorgement,  because  the  teething  process  is  often  ac- 
■companied  by  convulsive  seizures  ;  but  in  these  cases,  if  cerebral  hyperse- 


CONGESTION  OF  THE  BRAIN — MORBID  ANATOMY.  317 

mia  occur,  it  is  as  likely  that  the  convulsive  seizures  are  the  cause  of  the 
congestion  as  that  the  congestion  determines  the  fits.  The  intense  con- 
gestion of  the  face,  and  the  swelling  of  the  veins  of  the  neck,  which  are 
always  present  in  a  convulsive  fit,  show  that  there  is  impediment  to  the 
return  of  blood  from  the  head  ;  at  the  same  time  the  heart's  action  is  ex- 
cited, and  blood  is  being  propelled  rapidly  into  the  cranium.  There  must 
be  therefore  great  engorgement  of  the  vessels  in  this  region,  and  if  the 
fits  are  frequently  repeated  and  the  child  remains  for  hours,  as  often  hap- 
pens, in  a  more  or  leas  convulsed  state,  the  engorged  vessels  must  relieve 
themselves  by  effusion  of  serum,  and  perhaps  by  minute  haemorrhages. 
Pressure  upon  the  brain  set  up  by  this  means  is  sufficient  to  account  for 
the  stupor,  squinting,  etc.,  which  are  often  found  to  foUow  a  convulsive 
seizure  ;  but  the  effusions,  are  in  all  probability  like  the  venous  congestion 
itself,  a  consequence  rather  than  a  cause  of  the  nervous  commotion. 

Even  in  cases  where  the  cerebral  congestion  has  preceded  the  convul- 
sion, it  seems  probable  that  something  besides  mere  distention  of  ves- 
sels, unless  this  be  extreme,  is  necessary  to  give  rise  to  the  eclamptic 
seizure.  Some  time  ago  I  was  asked  to  see  a  httle  child,  aged  six  months, 
who  had  impetigo  of  the  head.  The  cervical  glands  of  both  sides  were 
enlarged  and  had  set  up  considerable  pressure  upon  the  veins  of  the  neck 
— enough,  indeed,  to  induce  great  oedema  of  the  head  and  face.  In  this 
case,  where  there  must  have  been  serious  imjDediment  to  the  return  of 
blood  from  the  brain,  there  were  no  signs  of  nervous  disturbance.  So  in 
cases  of  enlarged  bronchial  glands  with  pressure  upon  the  vasctdar  trunks 
in  the  chest,  oedema  of  the  head  and  neck  is  sometimes  produced,  and 
some  heaviness  may  be  complained  of  ;  but  convulsions  are  not  a  symptom 
of  the  disease. 

It  appears  probable  that  in  many  cases,  in  addition  to  the  engorged 
state  of  the  blood-vessels,  small  embohsms  or  thromboses  in  the  minute 
arteries  and  capillaries  of  the  brain  may  be  agents  in  the  production  of 
nervous  symptoms.  Dr.  Bastian  found  this  condition  of  the  brain  in  per- 
sons who  had  died  whilst  suffering  from  dehrium  and  coma  in  the  course 
of  acute  specific  diseases,  and  has  recorded  his  belief  that  minute  and 
widespread  congestions  are  often  a  consequence  of  these  obstructions. 
There  is  no  reason  to  suppose  that  young  children  differ  in  this  respect 
from  older  persons  ;  and  probably  the  convulsive  seizures  which  often  oc- 
cur towards  the  close  of  measles,  scarlatina,  and  other  infectious  fevers, 
may  owe  their  origin  not  to  the  accompanying  congestion,  but  to  minute 
plugging  of  the  cerebral  capillaries.  Such  vascular  obliterations,  if  widely 
distributed,  must  produce,  as  Dr.  Bastian  remarks,  "  total  disturbance  in 
the  incidence  of  blood-pressure,  and  in  the  conditions  of  nutritive  supply 
in  the  convolutional  gray  matter  of  the  brain." 

Besides  the  eruptive  fevers  and  convulsive  attacks,  exposure  to  extreme 
heat  and  cold,  or  direct  violence  applied  to  the  head,  may  be,  directly  or 
indirectly,  detei'mining  causes  of  acute  hyjpersemia  of  the  brain.  A  passive 
congestion  may  be  induced  in  the  child  during  a  difficult  labour  ;  it  is 
sometimes  the  consequence  of  energetic  expiratory  effort  in  whooping- 
cough  ;  it  may  be  set  up  by  diseases  of  the  heart  and  lungs,  or  by  other 
causes  which  interfere  with  the  return  of  blood  from  the  head  ;  and  it  may 
be  induced  by  the  pressure  of  intracranial  growths  upon  the  cerebral 
sinuses  and  veins. 

Morbid  Anatomy. — A  congested  brain  has  a  swollen  appearance.  The 
dura  mater  is  tightly  stretched,  and  if  slits  are  inadvertently  made  in  the 
membrane  in  the  process  of  removal  of  the  calvarium,  the  organ  bulges 


318  DISEASE  IE"   CHILDREN. 

tbrougli  the  artificial  opening.  The  convolutions  look  broad.  They  are 
flattened  by  pressui-e  against  the  bones  of  the  skull,  and  their  sulci  are  nar- 
rowed. The  veins  of  the  pia  mater  are  engorged,  tortuous,  or  even  vari- 
cose ;  and  the  small  vessels  are  filled  to  their  minute  ramifications.  The 
cranial  sinuses  are  distended  with  thick,  dark,  partially  coagulated  blood, 
and  the  choroid  plexuses  are  also  congested.  The  gray  matter  of  the  brain 
is  also  darker  than  natural,  and  its  section  shows  fine  dots  from  the  in- 
jected vessels.  The  white  substance  also  contains  numerous  red  points, 
and  sometimes  the  ^cerebral  tissue  is  oedematous,  with  excess  of  fluid  in 
the  ventricles.  In  cases  where  the  congestion  has  existed  for  some  time, 
httle  masses  of  blood  pigment  may  be  found  lying  outside  the  vessels 
within  the  lymphatic  sheath.  These  are  described  by  Bastian  as  molecular 
gi'ains  of  a  dark  ohve  or  amber  colour. 

Symptoms. — Signs  of  general  irritabihty  of  the  nervous  system,  such 
as  heat  of  head,  fretfulness,  dislike  to  light  and  noise,  disturbed  sleep, 
startings  and  twitchings,  have  been  said  to  constitute  an  early  stage  of  cere- 
bral congestion.  Such  symptoms  in  imj^ressionable  infants  frequently  ac- 
company digestive  disturbance  and  teething,  but  are  more  probably  due 
to  reflex  irritation  of  the  nervous  centres  than  to  engorgement  of  the  cere- 
bral capillarieiB  and  veins.  They  are  often,  perhaps,  accomjpanied  by  in- 
creased activity  of  the  cerebral  circulation,  but  are  not  necessai-ily  induced 
by  it.  The  so-called  "  ii'ritative  stage  "  of  cerebral  congestion,  then  ap- 
pears to  me  to  be  one  which  cannot  be  chnically  recognised,  at  least  I 
know  of  no  evidence  to  show  that  the  symptoms  said  to  be  characteristic 
of  this  stage  have  any  necessary  relation  to  an  engorged  state  of  the  cere- 
bral circulation. 

The  common  form  in  which  congestion  of  the  brain  is  met  with  in 
practice  is  that  in  which  an  infant  who  has  been  taken  with  Alolent  convul- 
sions from  teething,  or  other  form  of  reflex  mitation,  is  left  di'owsy  and 
stupid  after  the  fits  have  subsided.  Instead  of  clearing  quickly  away  the 
hea^dness  continues.  The  child  hes  with  his  head  retracted  on  his 
shoulders,  sometimes  he  vomits,  and  he  may  even  squint.  In  these  cases 
congestion  with  effusion  of  serosity  into  the  lateral  ventricles,  and  perhaps 
the  substance  of  the  bram,  appears  to  be  an  important  agent  in  the  pro- 
duction of  the  sjnnptoms.  In  cases  of  death  v/e  find  excess  of  fluid  in 
the  ventricles  ;  the  volume  of  the  brain,  is  increased,  the  convolutions  are 
flattened,  and  the  vessels  of  the  brain  and  the  pia  mater  are  engorged  with 
blood.  Such  a  case  has  akeady  been  narrated  in  the  chapter  on  convul- 
sions. Another,  which  seems  to  have  been  of  a  similar  kind,  although  it 
ended  differently,  is  the  following  : 

A  httle  boy,  seven  months  old,  a  strong,  healthy-looking  child,  who 
was  being  brought  up  at  the  breast,  and  had  cut  four  of  his  teeth,  was 
suddenly  attacked  with  vomiting  and  pru'ging.  The  symptoms  appear 
to  have  been  severe,  for  after  a  few  hours  the  child  fell  into  a  lethargic 
state  in  which  he  lay  for  four  days.  At  the  end  of  this  time  he  had 
a  fit  which  lasted  six  hours.  For  the  next  ten  days  he  was  di'owsy  and 
half  stupefied.  His  bowels  were  confined  and  once  or  twice  he  vom- 
ited. 

When  I  saw  the  child,  on  April  8th,  he  was  lying  in  his  mother's  arms 
with  his  eyes  half  closed.  His  face  was  very  pale,  the  pupils  were  equal, 
dilated,  and  immovable  ;  there  was  no  squint ;  the  fontaneUe  was  very  ele- 
vated and  tense ;  the  head  was  retracted  and  the  muscles  at  the  back  of 
the  neck  felt  rigid.  The  temperatui-e  in  the  rectimi  was  99°,  the  pulse  and 
respiration  could  not  be  coimted  for  irregularity.     The  lungs  and  heart 


COISTGESTION   OF   THE   BRAIlSr — SYMPTOMS — DIAGjSTOSIS.      319 

■were  healthy.  The  child  took  the  breast  weU,  and  sucked  vigorou£4y  but 
by  snatches. 

He  remamed  in  this  state,  vomiting  occasionally,  until  Apiil  12th-  when 
the  sickness  ceased  and  the  patient  seemed  very  much  better.  When  seen 
on  the  15th  he  appeared  to  be  quite  sensible.  The  j^upils  were  dilated 
and  acted  imperfectly  with  hght,  i.e.,  when  the  eyelids  were  suddenly 
opened  the  puj)ils  could  not  be  seen  to  contract.  The  fontaneUe  was  now 
rather  depressed.  Pulse,  168,  very  weak  but  regular.  Skin  cool.  Head 
not  retracted.  After  this  the  child  soon  became  quite  well,  except  that 
for  some  time  afterwards  he  had  a  peculiar  stare,  the  eyes  being  directed 
downwards,  so  as  to  show  a  rim  of  white  above  the  cornea. 

It  is  difficult  to  say  to  what  these  symptoms  were  due  if  congestion  of 
the  brain  and  effusion  of  fluid  induced  by  the  con-snilsion  were  not  the 
cause  of  them.  The  normal  temperature  seemed  to  exclude  any  inflamma- 
tory condition ;  while  the  somnolence,  the  immobility  of  pupUs,  the 
swoUen  and  tense  state  of  the  fontanelle,  and  the  retracted  head  pointed 
to  some  increase  of  pressure  within  the  skull  cavity.  If  we  assume,  on  the 
strength  of  Dr.  Bastian's  observations,  that  the  congestion  is  the  conse- 
quence of  wide-spread  minute  emboli  obstructing  the  circulation  through 
the  brain,  the  frequent  occurrence  of  symptoms  such  as  the  above  is  less 
difficult  to  account  for. 

Cases  have  been  recorded  and  attributed  to  cerebral  congestion  in 
wliich  loss  of  consciousness,  with  pyrexia,  squinting,  and  general  paralysis 
occurred,  and  passed  off  completely  after  a  few  days  or  hours.  It  is  diffi- 
cult to  understand  how  a  simple  local  congestion  alone  can  give  rise  to 
elevation  of  temperature  even  in  a  young  child.  Such  cases  are  obscure, 
and  no  sufficient  explanation  of  them  has  yet  been  anived  at. 

Many  cases  of  so-called  congestion  of  the  brain  are  probably  the  con- 
sequence of  thi'ombosis  of  the  cerebral  sinuses.  Dr.  Lewis  Smith  has 
shown  this  to  be  sometimes  the  case  in  pertussis  ;  and  convulsions  due  to 
other  causes  may  be  accompanied  by  similar  obstmctions  to  the  venous 
passages  within  the  skull.  Exact  observations  upon  this  point  are  to  be  de- 
sired ;  but  it  is  probable  that  increased  knowledge  v*ill  in  course  of  time 
greatly  diminish  the  importance  of  mere  fulness  of  cerebral  veins  as  an 
agent  in  the  production  of  nervous  distui'bance. 

Diagnosis. — -When  we  see  a  child  who  is  suffering  from  symptoms  indi- 
cative of  oppression  of  the  brain,  such  as  di'owsiness,  immobility  of  pupils, 
an  elevated  tense  fontanelle,  and  a  retracted  head,  we  have  to  distinguish 
the  case  from  one  of  meningitis  or  other  serious  cerebral  disease.  The 
history  is  here  of  the  utmost  importance.  If  the  symptoms  began  with  a 
convulsive  attack  preceded  merely  by  signs  of  irritability  of  the  nervous 
system,  such  as  usually  usher  in  a  fit  of  eclampsia  ;  if  the  child  be  the  sub- 
ject of  rickets,  and  if  some  cause  such  as  swoUen  inflamed  gums,  otalgia, 
or  digestive  derangement,  can  be  discovered  to  account  for  the  nervous 
seizure,  we  may  consider  the  symptoms  to  be  due  to  fiUing  of  the  cerebral 
vessels  and  effusion  of  semm  into  the  cranial  cavity.  If  the  temperature 
be  low,  it  is  a  confirmation  of  this  diagnosis.  Often,  however,  in  these 
cases  the  heat  of  the  body  is  increased  as  a  consequence  of  the  cause  which 
has  provoked  the  convulsion.  Therefore  a  high  temperature  is  not  neces- 
sarily to  be  interpreted  as  casting  any  doubt  upon  the  accuracy  of  this 
opinion.  In  simple  meningitis,  which  begins  with  violent  convulsions 
followed  by  drowsiness  and  stupoi*,  there  is  often  a  history  of  chronic 
otorrhoea  ;  and  in  most  cases  the  convulsion  has  been  preceded  by  signs 
of  pain  in  the  head.     But  besides  the  history,  the  symptoms  in  the  two 


320  DISEASE  IlSr   CHILDRElSr. 

diseases  differ  in  important  particulars.  In  meningitis  the  cliild  is  at 
once  seen  to  be  seriously  ill.  He  refuses  his  food,  and  is  restless  ;  he  con- 
tracts his  brows,  raises  his  hand  to  his  head,  rolls  his  head  from  side  to 
side,  and,  although  heavy  and  stupid,  manifests  every  sign  of  suffering. 
The  temperature  is  high,  but  the  pulse  is  comparatively  slow  (70-80). 
The  fits  continually  recur,  leaving  the  child  more  and  more  stupid  and 
comatose.  The  pupils  become  unequal,  rigidity  of  the  joints  comes  on, 
and  the  chUd  dies. 

In  cases  of  congestion  and  effusion  upon  the  brain  the  child,  although 
heavy  and  stupid,  is  quiet  and  shows  no  distress.  Usually  he  takes  his 
bottle  well,  and  this  is  an  important  sign.  The  fits  are  rarely  repeated 
after  the  drowsiness  has  become  marked.  The  pupils,  although  sluggish, 
are  not  unequal  in  size  ;  and  although  the  head  may  be  retracted  there  is 
no  rigidity  of  the  joints. 

Tubercular  meningitis  sometimes,  although  rarely,  begins  with  a  con- 
vulsion ;  but  unless  the  cerebral  symptoms  occur  as  a  terminal  phase  of 
acute  general  tuberculosis,  the  disease  afterwards  runs  its  normal  course, 
which  is  very  unlike  that  of  cerebral  congestion.  It  must  be  remembered, 
however,  that  a  primary  tubercular  meningitis  is  a  rarity  under  the  age  of 
two  years,  while  the  cases  of  cerebral  congestion  we  have  been  considering 
are  almost  limited  to  the  first  two  years  of  Hf  e.  The  difference  of  age  is 
therefore  an  important  element  in  the  diagnosis.  Still,  apart  from  other 
considerations,  congestion  of  the  brain  may  be  usually  recognised  by  re- 
marking that  although  drowsy  and  stupid  the  child  is  not  actually  uncon- 
scious ;  that  he  continues  to  take  his  bottle  well ;  that  his  pupils  are  never 
unequal ;  that  there  is  no  rigidity  of  joints,  and  that  loss  of  power,  although 
it  may  occur  as  a  consequence  of  violent  convulsions,  passes  off  in  a  few 
hours  unless  there  be  some  cause  for  it  more  serious  than  mere  exhaustion 
of  nervous  force.  The  occurrence  of  squint  lasting  more  than  a  few 
hours  is  very  suspicious  of  a  small  haemorrhage.  It  occurred,  however,  in 
the  case  narrated  in  another  chapter  (see  Convulsions),  without  anything 
being  discovered  in  the  brain  beyond  congestion  of  vessels  and  effusion  of 
serum. 

Prognosis. — There  is  always  reason  for  great  anxiety  when  a  young 
child  shows  signs  of  abnormal  heaviness  and  drowsiness.  The  mistake 
must  not,  however,  be  made  of  attributing  to  centric  disease  natural  sleepi- 
ness due  to  disturbed  rest  from  digestive  derangement.  It  happened  to 
me  once  to  be  summoned  some  distance  into  the  country  to  see  a  chUd  of 
a  few  weeks  old  who  was  said  to  have  congestion  of  the  brain  because  it 
was  always  falhng  asleep.  I  found  that  the  child's  bowels  were  disordered, 
and  that  it  was  evidently  tortured  by  frequent  griping  pains.  Every  few 
minutes  it  drew  its  legs  up,  bent  itself  backwards,  and  uttered  a  feeble 
cry.  After  some  seconds  its  features  relaxed,  its  eyes  closed,  and  it 
seemed  to  sleep,  but  almost  immediately  afterwards  it  was  aroused  by  a 
fresh  attack  of  pain.  This  state  of  things  had  continued  for  forty-eight 
hours.  During  all  that  time  the  child  had  been  prevented  from  obtaining 
natural  sleep  owing  to  the  abdominal  pains  which  roused  it  almost  as  soon 
as  its  eyes  were  closed.  After  a  good  dose  of  castor-oil,  which  relieved  its 
bowels  of  the  irritating  matter,  the  child  enjoyed  a  refreshing  sleep  and 
awoke  quite  well. 

The  majority  of  cases  of  stupor  following  convulsions  recover  ;  but  we 
should  be  careful  not  to  commit  ourselves  to  a  too  hopeful  prognosis  un- 
less improvement  begin  early  and  go  on  apace.  As  long  as  the  child  con- 
tinues to  take  his  food  well  the  prognosis  is  favourable.     If  he  refuse 


COK"GESTION   OF   THE  BEAIN — PROGNOSIS — TREATMENT.        321 

his  food,  if  the  drowsiness  deepen,  the  pupils  become  unequal,  or  squinting 
occur,  the  child  will  probably  die. 

"When  di-owsiness  is  noticed  in  children  as  a  result  of  impediment  to 
the  return  of  blood  from  the  head,  the  prognosis  is  determined  by  the  na- 
ture and  severity  of  the  disease  which  has  given  rise  to  the  passive  conges- 
tion. 

Treatment. — When  called  to  a  child  who  has  been  left  heavy  and  stupid 
by  an  attack  of  convulsions,  and  we  have  reason  to  fear  an  effusion  of  fluid 
into  the  skull  cavity,  our  first  care  should  be  to  clear  out  the  alimentary 
canal  by  a  dose  of  calomel  and  jalapine.  We  should  afterwards  keejD  up  a 
free  action  of  the  bowels  by  frequent  doses  of  any  suitable  saline  aperient. 
The  child  should  be  kept  perfectly  quiet  in  a  large  well  ventilated  room 
carefully  shaded  from  a  too  strong  light.  If  he  be  at  the  breast,  no  other 
food  should  be  allowed.  If  he  be  brought  up  by  hand,  milk  and  barley 
water  should  be  given,  and  but  little  farinaceous  food.  If  the  gums  are 
tense  and  swollen,  they  may  be  lanced  ;  but  unless  actual  irritation  arise 
from  this  cause  the  operation  is  better  avoided.  If  thought  desirable  cold 
may  be  applied  to  the  head.  In  some  cases  counter-irritation  with  mustard 
poultices  to  the  chest  and  spine  has  seemed  to  be  of  service. 

In  passive  congestion  the  treatment  is  that  of  the  disease  which  has 
given  rise  to  the  hypersemia. 
21 


CHAPTER  X. 

CEREBRAL  HEMORRHAGE. 

EuPTUEE  of  vessels  and  effusion  of  blood  into  the  brain  is  in  the  child  a 
comparatively  rare  accident.  lu  new-born  babies,  however,  extravasation 
into  the  arachnoid  sac  (meningeal  haemorrhage)  is  not  uncommon  if  the 
labour  has  been  difficult  and  slow.  Indeed,  Cruveilhier  has  stated  that 
amongst  still-bom  children  one-thh-d  of  the  deaths  may  be  attributed  to 
this  cause.  Under  three  years  of  age  it  is  rare  to  meet  mth  any  other 
form  of  intracranial  haemorrhage  than  that  into  the  arachnoid,  or  the 
meshes  of  the  pia  mater,  although  Billiard  found  a  clot  in  the  left  corpus 
striatum  in  an  infant  only  three  days  old,  and  B^rard  found  a  similar 
lesion  in  a  child  of  eight  months.  But  after  the  third  year  a  true  cerebral 
hsemon'hage  is  more  likely  to  occiu-,  and  sometimes  it  produces  much  the 
same  symptoms  as  are  found  in  the  adult  to  accompany  a  clot  in  the  brain. 

Causation. — When  meningeal  haemorrhage  occiu-s  during  birth  it  is  in 
cases  where  the  head  of  the  foetus  is  locked  in  the  brim  of  the  pelvis,  and 
the  bones  of  the  skull  are  forced  to  overlap  from  the  pressm-e  brought  to 
bear  upon  them.  If  it  occm-  after  the  bu-th  of  the  child  it  is  usually  a 
secondary  affection,  and  may  be  induced  by  any  cause  Avhich  is  "capable  of 
giving  rise  to  severe  and  long-continued  congestion  of  the  brain.  Thus 
it  may  be  found  in  cases  of  thrombosis  of  the  cranial  sinuses  ;  it  may  be 
induced  by  tumours  of  the  brain  pressing  upon  the  torcular  Herophih  and 
the  veins  of  Galen  ;  it  may  be  a  consequence  of  convulsions  or  whooping- 
cough,  and  it  is  said  to  be  often  found  in  cases  of  death  from  infantile 
tetanus.  It  appears  to  be  predisposed  to  by  conditions  which  lead  to  de- 
bility and  cachexia,  such  as  bad  feeding  and  acute  exhausting  disease. 

The  same  agencies  which  induce  cerebral  haemorrhage  in  infants  may 
cause  extravasations  of  blood  into  the  skull  cavity  of  older  children.  In 
these  subjects  the  haemorrhage  may  take  place  into  the -meninges,  the  ven- 
tricles, or  the  substance  of  the  brain.  In  haemorrhagic  purpura  the  menin- 
ges of  the  brain,  like  other  parts  of  the  body,  are  occasionally  the  seat  of 
extravasations  of  blood.  In  many  cases,  especially  when  the  effusion  occurs 
between  the  dura  mater  and  the  skull,  the  haemorrhage  may  be  attributed 
to  a  traumatic  cause.  Children,  too,  hke  adults,  may  die  from  that  com- 
paratively rare  accident — rupture  of  an  aneurism  on  the  brain.  Cerebral 
aneurism  occurs  in  early  life  much  more  frequently  than  the  ordinary 
forms  of  aneurism.  Out  of  seventy-nine  cases  collected  by  Dr.  Peacock  no 
less  than  four  were  found  in  children  between  the  ages  of  thirteen  and  fif- 
teen years,  and  a  boy,  twelve  years  of  age,  recently  died  of  this  disease  in 
the  Victoria  Park  Hospital,  under  the  care  of  one  of  my  colleagues.  Still, 
liable  as  children  are  to  cerebral  disease,  haemorrhage  into  or  on  the  bi'ain 
is  not  common  in  young  subjects,  so  far  at  least  as  can  be  judged  from  the 
results  of  post-mortem  examinations. 

Morbid  Anatomy. — In  young  subjects  hasmorrhage  is  in  general  capil- 


CEBEBEAL  H^MOEEHAGE — MOEBID   AISTATO.AIY.  323 

lary.  Rupture  occurs  in  small  vessels  and  the  effasion  of  blood  is  gradual. 
In  the  meninges  of  the  brain  the  extravasation  usually  takes  place  in  the 
arachnoid  sac  ;  but  it  may  be  also  formed  between  the  diu'a  mater  and  the 
bone,  in  the  meshes  of  the  pia  mater,  and  in  the  lateral  ventricles.  In 
the  arachnoid  sac  the  blood  is  either  liquid,  of  the  consistence  of  syrup, 
or  is  separated  into  a  solid  and  a  hquid  portion.  On  opening  the  cranium 
the  dura  mater  is  of  a  deep  violet  colour  from  the  presence  of  the  dai'k 
clot  beneath  it.  On  examination  this  clot  is  seen  to  be  spread  over  the 
surface  of  the  brain.  It  usually  occupies  the  situation  of  the  posterior  lobes 
and  the  cerebellum,  and  may  even  reach  as  far  as  the  vertebral  canal.  It 
is  thickest  in  the  centre  unless  a  part  of  it  covers  the  fissure  between  the 
hemispheres,  in  which  case  it  is  usually  thickest  at  this  spot,  as  it  here 
di23S  down  towards  the  fornix.  Towards  the  circumference  it  thins  off, 
and  is  usually  continued  for  some  distance  as  a  false  membrane  which  re- 
sults from  absorption  of  the  colouring  matter  of  the  efiiised  blood.  This 
false  membrane  near  the  clot  is  readily  distinguishable,  but  it  fades  grad- 
ually towards  the  edges  and  is  lost  on  the  sui'face  of  the  arachnoid.  The 
clot  generally  adheres  slightly  to  the  parietal  layer  of  the  arachnoid,  al- 
though it  may  be  readily  separated,  and  the  membrane  beneath  it  has  a 
perfectly  normal  appearance.  The  visceral  layer  of  the  arachnoid,  however, 
is  often  thickened  and  opaque.  The  clot  and  resulting  false  membrane 
are  in  rare  cases  stratified — an  appearance  j)i'C)bably  produced  by  succes- 
sive additions  to  the  original  extravasation.  Sometimes  we  find  more  than 
one  clot,  the  effusion  having  taken  place  at  various  points.  The  thickness 
may  be  from  a  few  lines  to  an  inch  or  more. 

A  certain  amount  of  fluid,  more  or  less  coloured,  bathes  the  surface  of 
the  clot ;  and  if  the  child  live  long  enough  the  liquid  may  become  enclosed 
in  a  species  of  cyst  formed  by  more  or  less  complete  adhesion  of  the  edges 
of  the  false  membrane  to  the  surface  of  the  arachnoid  covering.  Some- 
times the  cyst  is  loculated,  and  the  contents  may  increase  in  quantity  by 
subsequent  secretion.  In  a  case  reported  by  ]\OI.  Eilliet  and  Barthez  a 
double  cyst  was  found,  each  chamber  containing  more  than  half  a  htre  of 
fluid.  When  the  collection  of  fluid  is  thus  considerable,  it  presses  out- 
wards the  fontanelle  and  the  bones  of  the  skull  so  as  to  form  a  real  hydro- 
cephalus. 

It  is  rare  to  find  h?emorrhage  in  the  ventricles ;  but  it  may  occur  either 
in  the  walls  of  the  lateral  ventricles  or  into  their  cavities.  Hfemorrhage 
into  the  substance  of  the  brain  is  also  an  iincommon  lesion,  although  it 
may  occur  in  infants  and  children  of  any  age.  It  is  seldom  copious.  Usu- 
ally when  it  takes  place  it  is  in  the  course  of  some  other  form  of  illness, 
and  perhaps  on  this  account  often  escapes  recognition  dui'ing  life.  The 
blood  is  seen  in  minute  i^oints  scattered  about  the  cerebral  tissue,  or  may 
be  found  collected  in  little  ca\T.ties  in  the  brain-substance.  These  two 
forms  are  about  equally  common.  The  larger  collections  of  blood  vary  in 
size  from  a  pea  to  a  walnut.  Around  them  the  brain-tissue  is  normal,  or 
tinted  with  rose  colour,  or  slightly  softened.  The  haemorrhages  may  be 
found  at  any  part  of  the  brain-substance,  but  are  much  less  common  in 
the  cerebellum  than  in  the  cerebrum.  Besides  haemorrhages  we  often  find 
in  these  cases  much  congestion  of  the  brain  ;  and  there  may  be  also  other 
lesions,  such  as  meningitis  and  even  tubercles  of  the  brain,  as  in  a  case  to 
be  afterwards  referred  to. 

Cases  of  aneurism  of  a  cerebral  artery  in  young  subjects  are  almost  in- 
variably associated  with  endocarditis,  and  it  is  generally  held  that  the  ar- 
terial dilatation  is  the  consequence  of  embohsm.     It  is  probable,  also,  that 


324  DISEASE  iisr  children. 

cerebral  laasmorrliage  in  the  child  is  more  often  tlie  result  of  aneurism  than 
is  commonly  su.pposed,  for  this  may  be  easily  overlooked.  As  Sir  William 
Gull  has  observed,  "when  death  takes  place  from  changes  around  the 
aneurism,  as  by  pressure  or  softening,  the  sac  itself  may  present  such  ap- 
pearances that  unless  a  minute  dissection  be  made  of  it,  its  true  nature 
may  not  be  discovered."  The  mechanism  by  which  the  aneurismal  dilata- 
tion is  produced  is  doubtful.  Dr.  Ogle  attributed  it  to  the  impaction  of 
the  fibrinous  clot,  and  supposed  that  this  afterwards  softened  and  involved 
the  coat  of  the  vessel  in  the  process.  Dr.  Groodhart  has  suggested  that  in 
many  cases  the  clot  is  given  off  from  a  valve  the  seat  of  ulcerative  endo- 
carditis, that  this  poisons  the  part  where  it  lodges  and  "leads  to  acute 
softening  of  the  arterial  wall  by  inoculating  it  with  its  own  inflammatory 
action.''     This  explanation  is  not,  however,  of  universal  applicability. 

SymptoiiiH. — The  symptoms  of  meningeal  haemorrhage  are  unfortunately 
far  from  being  characteristic  of  the  lesion  to  which  they  are  owing.  This 
form  of  intracranial  haemorrhage,  indeed,  may  give  rise  to  no  symptoms  at 
all.  According  to  M.  Parrot,  in  infants  reduced  by  long-continued  bad 
feeding  to  a  cachectic  state  meningeal  haemorrhage  is  not  unfrequently 
foiind,  although  during  life  nothing  unusual  in  the  condition  of  the  child 
had  been  noticed  to  excite  a  suspicion  of  this  serious  complication.  On 
the  other  hand,  in  new-born  babies  extravasation  of  blood  into  the  arach- 
noid sac  may  be  accompanied  by  violent  convulsions  and  end  in  death 
within  a  few  hours.  Such  a  case  is  recorded  by  Valleix.  A  well-developed, 
healthy-looking  male  infant  received  a  violent  bruise  on  the  shoulder  two 
days  after  birth.  He  seemed  to  be  going  on  favourably  when,  on  the 
sixth  day,  he  was  seized  with  strong  convulsions,  which  were  repeated  with 
violence,  and  in  three  hours  the  child  was  dead.  On  examination  of  the 
body  a  large  clot  was  found  in  the  ai'achnoid  sac  ;  the  veins  of  the  pia  ma- 
ter were  swollen  with  blood  ;  the  substance  of  the  brain  was  injected  ;  and 
the  superior  longitudinal  sinus  was  filled  with  a  whitish,  semi-transparent, 
gelatinous  thrombus.  In  this  case  the  convulsions  must  not  be  attributed 
entirely  to  the  haemorrhage.  No  doubt  the  thrombosis  had  a  great  share 
in  the  production  of  the  symptoms,  and  it  was  apparently  the  cause  of 
the  extravasation.  Convulsions  are,  however,  a  common  consequence  of 
arachnoid  haemorrhage  and  repeatedly  recur. 

Legendre  has  described  a  febrile  form  of  meningeal  haemorrhage  in 
which  the  disease  begins  with  vomiting  and  pyrexia.  Convulsive  seizures 
soon  come  on,  limited  at  first  to  the  ocular  muscles  and  giving  rise  to  a 
slight  squint.  The  child  sucks  well,  probably  from  thirst,  and  his  bowels 
are  in  a  normal  state.  Soon  contractions  are  noticed  of  the  fingers  and 
toes,  and  general  convulsions  follow,  both  tonic  and  clonic,  during  which 
consciousness  is  lost  and  the  face  becomes  of  a  dusky  red  tint.  For  a  time 
the  convulsions  are  comparatively  infrequent,  and  in  the  intervals  the  child 
is  heavy  and  drowsy.  After  a  few  days  the  heaviness  deepens  into  stupor, 
the  intervals  between  the  fits  become  shorter  and  shorter,  and  towards  the 
end  of  the  illness  the  infant  is  almost  constantly  convulsed.  The  fever 
persists  throughout,  and  death  is  often  hastened  by  an  intercurrent  in- 
flammatory complication  of  the  limgs. 

The  above  is  generally  accepted  as  representing  the  ordinary  course  of 
an  attack  of  meningeal  haemorrhage  in  the  young  child  ;  but  if  it  induces 
us  to  look  for  elevation  of  temperature  as  an  essential  part  of  the  illness 
it  is  certainly  misleading.  Statements  with  regard  to  temperature,  made 
in  days  before  the  thermometer  came  into  use  as  an  aid  to  cHnical  in- 
vestigation, should  be  accepted  with  caution.    Moreover,  in  each  of  the  two 


CEKEBEAL   HiEMOKEHAGE — SYMPTOMS.  325 

illustrations  appended  by  the  author  to  his  description  of  the  disease,  a 
double  catarrhal  jDneumonia  was  found  to  occupy  the  lungs  ;  and  this 
complication  would  amply  explain  any  elevation  of  temperature  which 
might  have  been  noticed  during  life.  In  cases  of  intracranial  haemorrhage 
unaccompanied  by  an  inflammatory  condition  of  other  organs  the  temper- 
ature, as  is  shown  by  a  case  narrated  later,  is  not  raised  above  the  normal 
level. 

The  chief  difficulty  in  assigning  to  this  form  of  haemorrhage  its  dis- 
tinctive symptoms  arises  from  the  fact  that  it  is  rare  to  find  a  case  in 
which  the  haemorrhage  was  not  secondary  to,  or  complicated  by,  some 
other  malady.  Even  in  instances  where  no  morbid  condition  of  other 
organs  is  to  be  discovered  it  is  an  open  question  whether  the  convulsions 
which  are  invariably  present  in  such  cases  give  rise  to  the  haemorrhage  or  the 
haemorrhage  to  the  convulsions.  It  is  worthy  of  remark  that  paralysis  is 
seldom  a  consequence  of  meningeal  haemorrhage.  The  symptoms,  indeed, 
are  very  much  those  of  meningitis  affecting  the  convexity  of  the  brain, 
with  the  important  exception  that  in  cases  of  haemorrhage  there  is  no 
pyrexia.  They  also  diifer  from  them  in  the  fact  that  there  are  no  signs  of 
headache,  and  that  at  first  the  stupor  is  not  profound.  Infants  with  ex- 
travasation of  blood  into  the  meninges,  according  to  the  testimony  of  all 
published  cases,  take  the  bottle  well  for  a  time.  This  is  no  doubt  owing 
to  thirst  rather  than  to  any  appetite  for  food.  Still,  the  fact  remains  that 
while  in  arachnoid  h.Tmorrhage  the  child  takes  food  with  avidity,  in  simple 
meningitis  of  the  convexity  of  the  brain  he  makes  httle  attempt  to  suck, 
and  generally  refuses  the  bottle  altogether. 

Haemorrhage  into  the  meninges  or  on  to  the  surface  of  the  brain  is  not 
confined  to  infants.  A  little  girl,  aged  eight  years,  was  a  patient  in  the 
Victoria  Park  Chest  Hospital,  for  heart  disease  and  dropsy.  The  heart 
was  enlarged  in  all  directions  ;  praesystolic  and  systolic  murmurs  were 
heard  at  the  apex  ;  there  was  much  oedema  of  the  lower  extremities,  and 
the  urine  contained  one-third  of  albumen.  The  child  was  kept  in  bed  and 
made  considerable  progress  for  about  a  fortnight,  when  some  thrombosis 
was  noticed  in  the  basilic  and  internal  saphena  veins  of  the  left  side. 
About  a  week  afterwards  she  cried  out  one  morning  after  breakfast  with 
j)ain  in  her  head,  and  shortly  afterwards  became  convulsed.  Twitchings 
were  noticed  in  the  muscles  of  the  lower  part  of  the  face  on  the  left  side, 
involving  the  lips,  the  angle  of  the  mouth,  and  the  left  side  of  the  neck. 
The  face  was  turned  to  the  left.  There  were  also  convulsive  movements 
of  the  left  arm,  more  particularly  of  the  forearm,  wrist,  and  hand.  There 
were  no  movements  of  the  leg  on  that  side.  The  girl  died  in  the  course 
of  the  evening  after  a  series  of  these  convulsive  movements.  The  temper- 
ature was  normal  throughout. 

On  opening  the  superior  longitudinal  sinus,  after  death,  the  channel 
was  found  to  contain  a  decolourised  adherent  clot  which  reached  from 
nearly  the  anterior  extremity  to  the  posterior  third.  Opening  into  the 
sinus  was  a  vein  which  ran  from  the  right  cerebral  hemisphere.  This  was 
also  filled  with  a  clot,  but  less  decolourised  than  the  first,  and  the  surface 
of  the  brain  in  its  neighbourhood  was  the  seat  of  a  circumscribed  hemor- 
rhage. The  clot  was  bounded  posteriorly  by  the  fissure  of  Rolando,  and 
extended  anteriorly  over  the  posterior  part  of  the  superior  frontal  convo- 
lution on  the  right  side.  These  correspond  very  nearly  to  the  areas  de- 
scribed by  Ferrier,  as  connected  with  the  movements  of  the  lips,  tongue, 
and  mouth  ;  also  that  for  the  movements  of  the  arm  and  leg.  There  were 
no   convulsive  movements  of  the  left  leg,  but   this  was   the  seat  of   so 


326  DISEASE   IX    CHILDEEIST. 

mucli  cedenia  that  the  child's  o^^vu  voluntaiy  power  over  it  had  been  very 
smalL 

This  case,  for  the  notes,  of  which  I  am  indebted  to  Dr.  Lawrence  Hum- 
phry, the  resident  physician,  bears  a  very  close  resemblance  to  Valleix' 
case  before  referred  to,  although  occurring  in  a  much  older  child.  It  will 
be  remarked  that  the  temperature  during  the  convulsive  seizures  was  not 
elevated. 

"When  the  extravasation  of  blood  takes  place  into  the  substance  of  the 
hrain  the  first  symptom  is  usually  an  attack  of  convulsions.  Afterwards 
the  phenomena  may  resemble  those  peculiar  to  an  ajDOiDlectic  seizure  in  the 
adult.  It  is  probable  that  this  form  of  haemorrhage  is  less  uncommon 
than  might  be  inferred  fi'om  examinations  in  the  dead-house  ;  for  if  the 
amount  of  blood  effused  be  moderate,  the  child  may  recover  with  a  more 
or  less  extensive  paralysis.  In  jorimary  heemorrhages  I  beheve  this  is  not 
unfrequently  the  case.  In  hospital  practice  we  not  unfrequently  see  chil- 
dren who,  as  a  consequence  of  a  fall  or  some  injuiy  to  the  head,  are  seized 
Tsith  headache  and  convulsions,  and  are  then  found  to  be  paralysed  in  one 
half  of  the  body.  The  leg  often  recovers  after  a  few  weeks,  but  the  arm 
may  remain  more  or  less  pennanently  disabled  with  contraction  of  the  fin- 
gers. This  was  the  case  with  a  Httle  girl,  six  years  of  age,  who  was  lately 
a  patient  in  the  East  London  Childi'en's  Hospital.  In  addition  the  child 
was  aphasic,  and  could  not  be  jjersuaded  to  speak  during  her  stay  in  the 
hospital.  Otherwise  her  general  health  seemed  fanly  good,  and  she  did 
not  complain  of  headache.  The  case  imfortunately  coiild  not  be  followed 
out,  as  after  a  few  weeks  the  child  was  removed  by  her  friends ;  but  I 
have  httle  hesitation  in  ascribing  her  symptoms  to  a  small  clot  in  the 
brain. 

Often  the  cerebral  haemoiThage  is  only  one  of  several  lesions  occupying 
the  cranial  cavity.  It  is  then  difiicult  to  assign  to  each  its  due  share  in 
the  production  of  the  symptoms. 

A  httle  gii'l,  aged  fifteen  months,  with  ten  teeth,  was  brought  to  the 
hospital  on  July  13th.  According  to  the  mother's  account  the  child, 
although  hand-fed,  had  walked  at  the  age  of  ten  months,  and  had  always 
been  regarded  as  healthy  until  the  previous  March,  when  she  had  had  a 
fall  down  a  flight  of  stairs.  The  child  was  not  stunned  by  the  accident, 
but  vomited  and  "was  ill"  for  a  few  days.  She  then  began  to  lose  flesh 
and  ceased  to  inin  about,  always  crying  to  be  nursed.  On  June  ith,  she 
had  a  violent  convulsive  seizui-e  which  began  with  hiccough.  The  spasms 
were  hmited  to  the  left  side,  and  lasted  nine  houi's.  When  they  ceased 
the  left  arm  and  leg  were  noticed  to  be  powerless,  and  the  face  was  di'awn 
to  the  right  side. .  The  paralysis  jDassed  off  in  about  a  fortnight,  but  the 
child  remained  weakly.  She  began  "to  have  a  discharge  from  the  left  ear 
and  the  nostrils.  She  seemed  to  suifer  much  from  pain  in  the  head  ;  often 
vomited ;  and  the  bowels  were  somewhat  loose.  On  two  occasions  she  had 
general  convulsions  of  an  houi-'s  duration.     She  took  liquid  food  well. 

Towards  the  end  of  June  the  child  became  much  worse.  She  began 
to  cough  ;  her  breathing  was  rapid  ;  she  sighed  a  great  deal ;  seemed  very 
drowsy,  and  at  times  would  scream  out  suddenly  as  if  in  pain. 

On  admission  into  the  hospital  (on  July  13th)  the  temperature  was 
101°  ;  pulse,  160  ;  respirations,  88.  The  patient  was  fretful  and  screamed 
almost  incessantly  until  11  p.m.,  when  she  had  an  attack  of  general  convul- 
sions. At  this  time  her  temperature  was  104°.  On  the  following  morning 
she  was  found  very  pale  ;  the  fontanelle  was  depressed  ;  the  eyes  were 
turned  constantly  to  the  right ;  the  pupils  were  unecjual  and  insensible  to 


CEEEBRAL   HJEMOREHAGE — SYMPTOMS.  327 

light,  the  left  being  the  larger  of  the  two.  Both  arms  were  convulsed,  and 
the  right  leg  and  left  hand  were  rigid  ;  there  was  no  paralysis  of  the  face. 
The  hands,  feet,  and  nose  felt  cold,  although  the  temperature  in  the  rectum 
was  102.4°.  The  pulse  was  very  small,  170.  The  abdomen  was  soft  and 
not  retracted.  Pressure  on  the  skin  produced  Httle  flush.  On  examina- 
tion of  the  back  dulness  was  noted  on  both  sides  with  abundant  crepitat- 
ing rales.     After  this  the  child  remained  insensible  and  died  at  6  p.m. 

On  examination  of  the  body  much  yellow  lymph  was  found  covering 
the  right  middle  lobe  of  the  cerebrum.  There  was  an  old  clot,  the  size  of  a 
hen's  egg,  occupying  the  right  corpus  striatum  and  the  superjacent  part  of 
the  right  hemisphere.  Scattered  caseous  nodules,  the  size  of  a  large  pea, 
were  seen  in  the  right  hemisphere,  and  the  choroid  plexus  ;  and  some  gray 
granulations  were  discovered  on  the  vertex  of  the  brain  along  the  course  of 
the  vessels,  and  a  larger  number  at  the  base.  The  lungs  were  the  seat 
of  catarrhal  pneumonia.  The  hver,  spleen,  and  kidnej^s  contained  small 
yellow  nodules  ;  and  the  bronchial  and  mesenteric  glands  were  enlarged 
and  caseous. 

In  this  case  there  can  be  little  doubt  that  the  convulsions  and  hemi- 
plegia noted  on  June  4th  resulted  from  the  apoplectic  clot.  The  after- 
symptoms  were,  no  doubt,  the  consequence  of  the  meningitis  and  general 
tubei'culosis.  The  case  is  interesting  as  showing  that  a  copious  extravasa- 
tion is  not  necessarily  fatal ;  for  it  is  reasonable  to  sujDpose  that  had  the 
clot  been  the  sole  lesion  present  the  child  would  not  have  died. 

Cerebral  haemorrhage  in  the  child  is  not,  however,  always  accompanied 
by  symptoms  so  characteristic.  Violent  convulsions  and  sudden  death  may 
be  produced  by  a  clot  in  the  substance  of  the  brain  ;  or  a  child  may  be 
seized  with  repeated  vomiting  ;  may  then  be  taken  with  convulsions  ;  and 
afterwards  fall  into  a  state  of  unconsciousness  with  dilated  pupils,  rapid 
feeble  pulse,  and  cool  skin,  and  die  in  the  course  of  a  few  hours.  These 
were  the  symptoms  noticed  in  the  case  of  a  boy  who  died  in  the  Victoria 
Park  Hospital  from  ruptui'e  of  a  cerebral  aneurism.  The  notes  of  the  case 
were  kindly  furnished  to  me  by  Dr.  Humphry,  the  resident  physician. 

A  scrofulous-looking  boy,  aged  twelve  years,  was  admitted  into  the  hos- 
pital under  the  care  of  my  colleague.  Dr.  Birkett,  on  March  15th.  He  had 
had  scarlatina  four  years  before,  followed  by  dropsy,  and  there  was  besides 
a  doubtful  history  of  rheumatic  fever  at  about  the  same  time.  For  two 
years  the  patient  had  complained  of  shortness  of  breath,  which  had  lately 
been  getting  more  distressing.  When  admitted,  a  loud  mitral  murmur 
was  detected,  with  considerable  hypertrophy  of  the  heart. 

On  March  19th  the  boy  vomited  a  great  deal,  and  complained  of  head- 
ache. On  the  morning  of  March  20th  he  seemed  very  sleejDy,  but  made  no 
complaint.  At  11.30  a.m.  the  resident  physician  was  summoned  to  his  bed- 
side, as  the  boy  was  said  to  have  had  a  fit.  The  patient  had  vomited,  and 
appeared  to  be  very  drowsy,  but  he  answered  questions.  The  pupils  were 
equal  and  rather  contracted  ;  the  conjunctivae  were  sensitive,  and  there 
was  no  squint  or  other  sign  of  paralysis.  Shortly  afterwards  he  had  several 
quasi-fits  in  which  he  became  flushed.  His  eyes  rolled  from  side  to  side, 
and  the  conjunctivae  were  not  sensitive.  He  passed  water  in  the  bed. 
The  pupils  were  equal.  Temperature,  97.6°  ;  pulse,  84,  and  regular.  After 
this  the  coma  became  more  and  more  profound,  and  the  boy  died  at  4  p.m. 
On  examination  of  the  body  the  veins  over  both  hemispheres  were 
much  congested,  especially  on  the  right  side.  The  pia  mater  over  the 
whole  surface  was  suffused.  The  left  hemisphere  was  larger  than  the 
right,  and  the  convolutions  were  flattened.    At  the  base  of  the  brain  all  the 


828  DISEASE  IN   CHILDEEN. 

loose  tissue  of  the  araclmoid  was  filled  witli  dark  clotted  blood,  wliich  had 
spread  along  the  Sylvian  fissure  on  to  both  siu'faces  of  the  cerebellum  and 
downwards  along  the  cord.  Both  lateral  ventricles  were  completely  filled 
with  a  large  clot,  as  also  were  the  third  and  fourth  ventiicles.  From  the 
ventricles  the  blood  seemed  to  have  spread  by  the  transverse  fissure  to  the 
outer  portion  of  the  brain,  and  not  thi-ough  the  "iter."  The  source  of 
the  haemorrhage  was  a  small  aneurism,  of  the  size  of  a  small  pea,  seated 
on  the  Sylvian  artery  about  one  inch  from  its  beginning.  The  coats  of  the 
aneiuism  were  very  atheromatous  and  brittle.  The  ruptui-e  was  extensive 
along  the  top  of  the  aneurism,  and  the  blood  had  biu'st  into  the  top  of  the 
anterior  horn  of  the  left  lateral  ventricle.  Elsewhere  the  coats  of  the  ves- 
sels showed  no  sign  of  disease.  The  mitral  valve  was  much  beaded,  and 
the  pericardium  was  universally  adherent. 

Judging  from  the  variety  of  symptoms  found  as  a  result  of  cerebral 
haemorrhage  in  the  child  we  can  only  conclude  that  there  are  none  which 
can  be  considered  characteristic  of  this  lesion.  SymjDtoms  of  irritation  of 
the  brain  coming  on  suddenly,  and  followed  after  a  few  hours  by  sj-mptoms 
of  compression,  are  not  peculiar  to  hsemorrhagic  effusion  within  the  skull ; 
and  yet,  as  a  rule,  we  find  nothing  more  distinctive  than  these.  Still,  the 
very  fact  of  profound  depression  following  rapidly  upon  symptoms  of 
violent  mitation  in  a  non-pyretic  patient  may  give  rise  to  suspicions  of 
cerebral  haemorrhage,  especially  in  children  over  four  or  five  years  of  age. 

Diagnosis. — On  account  of  the  indefinite  chai-acter  of  the  symptoms, 
haemorrhage  into  the  brain  or  meninges  in  childhood  is  very  difBcult  to 
detect.  The  difficulty  is  increased  by  the  lesion  being  so  often  a  second- 
ary one,  occiu'ring  in  infants  and  young  children  who  ai-e  already  suffeiing 
from  other  complaints.  It  must  be  confessed  that  in  such  cases  intra- 
cranial haemorrhage  is  very  likely  to  be  overlooked.  Even  when  the  haemor- 
rhage is  primaiy  it  is  difficult  to  lay  down  rules  for  the  detection  of  the 
lesion. 

If  a  young  child,  whose  water  has  been  examined  and  found  to  be 
healthy,  be  seized  with  repeated  convulsions,  in  the  intervals  of  which,  al- 
though drowsy  and  stupid,  his  temperature  is  noiinal,  and  he  swallows 
liquid  food  vdth.  appetite,  we  may  hesitate  between  congestion  of  the  brain 
^vith  effiision  of  fluid  and  intra-crauial  haemorrhage.  If,  now,  we  notice 
that  after  the  stupor  has  become  marked  the  convulsions  continue,  and 
especially  if  any  contractions  and  rigidity,  more  than  merely  temporary, 
are  noticed  in  the  hands  and  feet,  the  temperature  remaining  low,  we  are 
justffied  in  susj)ecting  a  haemorrhage. 

"\Alien  hemiplegia  follows  an  attack  of  convulsions,  the  paralysis  is  not 
necessarily  a  s^Tuptom  of  haemorrhage,  for  the  same  phenomena  (convul- 
sions and  paradysis)  are  occasionally  seen  in  cases  of  tumour  of  the  brain. 
In  the  latter  disease,  however,  we  can  usually  obtain  a  history  of  severe 
and  paroxysmal  headache  ;  there  is  often  paralysis  of  ocular  muscles,  indi- 
cating imphcation  of  cerebral  nerves  ;  and  an  examination  of  the  eye  will 
generally  detect  the  presence  of  optic  neui'itis.  Contractions  and  rigidity 
of  the  fingers  and  toes,  T\T.ists  or  ankles,  may  occur  in  either  case.  If, 
after  recovery  of  consciousness  the  hemiplegia  persist,  but  the  child  re- 
main free  fi'om  headache,  if  the  retinae  are  normal  and  the  general  health 
seem  fairly  good,  a  cerebral  growth  may  be  excluded. 

A  diagnosis  between  haemorrhage  into  the  meninges  and  that  into  the 
substance  of  the  brain  is  probably  impossible  from  the  sym^Dtoms  alone, 
although  if  paralysis  occur  this  symptom  is  not  in  favour  of  meningeal 
extravasation.      The   age,   however,   is  here  of  importance.      Under  the 


CEREBRAL   HEMORRHAGE — DIAGj^OSIS — TREATMENT.        329 

third  year  haemorrhage  rarely  takes  place  into  the  cerebral  tissue.  In 
nine  cases  of  intracranial  hsemorrhage  occiuTing  in  infants  aged,  three 
years  and  under,  observed  by  M.  Legendre,  in  no  case  was  the  haemorrhage 
other  than  meningeal  After  that  age  haemorrhage  more  commonly  takes 
place  into  the  brain-substance,  as  it  does  in  the  adult. 

Prognosis. — In  all  cases  of  cerebral  haemorrhage  the  prognosis  is  very 
serious ;  and  it  is  especially  so  if  the  patient  in  whom  the  extravasation 
occur  be  the  subject  of  diathetic  disease,  or  be  weakened  by  recent  acute 
illness.  The  occurrence  of  paralysis  is  not  in  itself  a  necessarily  unfavour- 
able sign.  Of  greater  importance  is  the  degree  of  heaviness  remaining 
after  the  convulsions  have  ceased,  or  the  frequency  of  return  of  the  spas- 
modic movements  themselves.  As  long  as  the  child  continues  to  take 
liquid  food  we  may  hope  for  improvement.  If  he  refuse  his  bottle,  or 
cease  to  drink  when  the  feeding-cup  is  held  to  his  lips,  the  sign  is  a  very 
Tinfavourable  one.  The  condition  of  the  pupils  should  be  always  noticed. 
If  they  are  dilated  and  insensible  to  light  the  prognosis  is  bad  ;  if  they  are 
unequal  in  size  death  may  be  considered  certain. 

Treatment. — Cases  of  intracranial  haemorrhage  require  much  the  same 
treatment  as  has  been  ah'eady  recommended  for  congestion  of  the  brain. 
If  the  child  be  strong  an  ice-bag  should  be  apphed  to  his  head,  and  the 
bowels  should  be  freely  acted  upon  by  a  dose  of  calomel  and  jalap.  If 
the  heart's  action  be  violent,  and  the  arteries  of  the  neck  are  seen  to  pul- 
sate strongly,  digitalis  may  be  given  to  control  the  energy  of  the  cardiac 
contractions.  Three  drops  of  the  tinctui-e  of  digitaHs,  or  twenty  of  the 
infusion,  may  be  given  every  two  or  three  hours  to  a  child  of  twelve 
months  of  age.  The  patient  should  lie  with  his  head  raised  ;  and  if  the 
feet  are  cold,  a  hot  bottle  can  be  placed  at  the  bottom  of  the  cot.  If  the 
pulse  flag  or  the  fontanelle  become  depressed,  stimulants  should  be  given 
in  such  quantities  as  may  seem  desirable. 

The  food  should  consist  of  milk,  freely  diluted  with  barley  water,  or  of 
whey  and  barley  water.  It  is  better  in  these  cases  to  feed  the  child  with 
a  spoon,  or  at  any  rate  to  give  him  fluid  only  in  small  quantities  at  a  time, 
so  as  not  to  increase  the  strain  upon  the  vessels  by  a  rapid  introduction  of 
large  quantities  of  liquid  into  the  circulation. 

In  the  after-paralysis  little  can  be  done.  Our  efforts  must  be  re- 
stricted to  ordinary  measures  for  improving  the  general  health  and  pro- 
moting nutrition. 


CHAPTEK  XI. 

CEREBRAL   TUMOUR. 

Children,  like  adults,  are  subject  to  morbid  formations  in  the  brain 
which  may  give  rise  to  a  variety  of  symptoms  according  to  the  situation  of 
the  growth.  In  the  case  of  a  child,  however,  "tumour"  of  the  brain 
usually  means  "tubercle"  of  the  brain,  for  it  is  only  in  exceptional  cases 
that  any  other  form  of  cerebral  growth  is  to  be  found.  Still,  in  rare  in- 
stances cancerous,  glyomatous,  and  syphihtic  nodules  are  developed  in  this 
region,  and  occasionally  we  meet  with  the  cysticercus  cellulosa  or  the 
hydatid  cyst. 

3Iorhid  Anatomy. — Tubercle  of  the  brain  is  said  to  be  rare  under  the 
age  of  two  years ;  but  I  think  the  occurrence  of  the  disease  in  infants  is 
more  common  than  has  been  supposed.  It  is  seldom  seen  in  the  cranium 
without  other  organs  being  similarly  affected,  although  in  exceptional 
cases  it  may  be  a  solitary  instance  of  tubercular  formation  in  the  body. 
The  seat  is  most  frequently  in  the  cerebellum,  but  it  is  also  common  in 
the  hemispheres  of  the  brain.  Next  in  order  of  frequency,  according  to 
Andral,  come  the  pons,  the  medulla  oblongata,  the  peduncles  of  the 
cerebrum  and  cerebellum,  the  optic  thalamus,  and  the  corpus  striatum. 
In  number  there  may  be  one  or  more,  and  in  size  they  may  be  small  or 
large.  Usually  the  more  numerous  masses  are  of  small  dimensions. 
Single  tumours  may  be  as  small  as  a  pea  or  as  big  as  an  egg,  or  even  of 
stiU  larger  size  ;  but  they  are  most  commonly  met  with  about  equal  in 
volume  to  a  filbert  or  small  marble.  The  masses  are  almost  always  sur- 
rounded by  a  fibrous  covering  which  separates  them  from  the  brain-sub- 
stance around.  In  exceptional  cases,  however,  i.e.,  where  death  has  taken 
place  while  the  tumour  is  still  growing,  the  limits  of  the  mass  are  not 
thus  circumscribed,  but  its  substance  passes  insensibly  into  the  adjacent 
cerebral  tissue.  When  the  tumour  ceases  to  extend  itself,  an  areola  of 
connective  tissue  and  vessels  forms  at  its  circumference,  and  develops 
into  a  fibrous  envelope  which  varies  in  thickness  according  to  the  age  .of 
the  growth. 

On  section  the  tumours  are  yellowish  white,  or  have  a  faint  greenish 
tint,  and  are  found  to  consist  of  cheesy  matter.  Their  consistence  is 
more  or  less  firm,  but  the  centre  is  usually  softer  than  the  circumference, 
and  may  be  converted  entirely  into  a  creamy  pulp  so  as  to  give  the  appear- 
ance, with  the  firm  envelope,  of  a  little  bag  of  pus.  Tuberculous  matter 
found  in  the  brain  is  seldom  seen  in  any  other  shape  than  that  of  yellow 
caseous  matter.  Lebert  and  Rokitansky,  however,  agree  that  in  excep- 
tional cases  it  may  begin  as  the  gray  granulation  ;  but  it  seldom  remains 
long  in  this  stage  and  very  quickly  becomes  cheesy  and  yellow.  Ai'ound 
the  mass  the  brain-substance  may  be  natural,  or  congested,  or  more  or 
less  softened  by  oedema.  Often  the  collections  of  tubercle  spring  from  the 
pia  mater,  and  are  attached  to  it  by  a  fibrous  stalk  continuous  with  the 


CEREBRAL   TUMOUR — MORBID   ANATOMY — SYMPTOMS.         331 

envelope,  and  filled  like  it  with  tuberculous  or  cheesy  matter.  Tuber- 
culous meningitis  is  often  present,  and  is  the  direct  cause  of  death.  If 
the  mass  be  on  the  surface  of  the  cerebellum,  and  so  placed  as  to  press 
on  the  straight  sinus  or  the  vena  magna  Galeni,  it  may  be  a  cause  of 
chronic  hydrocephalus.  It  is  not  often  that  a  cretaceous  change  takes  place 
in  cheesy  matter  situated  in  or  upon  the  brain,  for  the  irritation  set  up  is 
usually  so  injurious  that  death  takes  place  before  this  transformation  has 
had  time  to  occur.     Still,  it  is  sometimes  met  with. 

Cancer  of  the  brain  is  rare.  When  it  occurs  it  is  usually  secondary  to 
a  similar  growth  in  the  eye  ;  or,  as  recorded  by  Steiner,  may  advance  in- 
wards from  the  skull.  When  thus  secondary,  it  may  appear  in  several 
centres.  The  size  of  the  mass  varies  from  a  pea  to  an  orange.  These  so- 
called  cancerous  growths  have  usually  the  characters  of  sarcoma. 

Gliomatous  tumours  of  the  brain  are  solitary  growths  which  increase 
slowly  in  size,  so  that  they  may  be  long  in  producing  appreciable  effects. 
They  often  reach  considerable  dimensions,  and  occupy  by  preference  one 
or  other  of  the  posterior  j3erebral  lobes.  Their  borders  are  not  well 
defined,  and  their  substance  passes  gradually  into  the  brain-tissue  around. 
Their  consistence  is  usually  firm,  and  they  are  rather  more  vascular  than 
the  cerebral  substance  in  which  they  are  embedded. 

Cysticerci,  the  second  stage  of  the  taenia  solium,  when  they  occur  in 
the  brain,  are  usually  numerous.  They  are  generally  found  in  the  gray 
substance  or  at  the  surface.  They  are  especially  partial  to  the  pia  mater, 
and  are  usually  more  or  less  embedded  in  the  gray  matter  of  the  convolu- 
tions. They  vary  in  size  from  a  pea  upwards.  Occasionally  they  die  and  • 
become  changed  into  a  thick  "mortar-like  "  substance  containing  booklets. 

Hydatids,  the  second  stage  of  the  taenia  echinococcus,  usually  exist, 
several  together,  enclosed  in  an  outer  sac.  The  most  frequent  situation  is 
the  centre  of  the  white  matter  in  one  of  the  hemispheres,  and  the  cyst 
may  grow  to  a  large  size.  The  hydatid,  although  rare  at  all  ages,  is  not 
proportionately  less  common  in  children  than  in  adults.  In  twenty-four 
cases  of  hydatids  of  the  brain,  collected  by  Dr.  Bastian,  in  which  the  age 
was  stated,  three  occurred  in  children  under  the  age  of  ten  years. 

SymiDtoins. — Tumours  of  the  brain,  if  they  grow  slowly,  if  they  are 
situated  at  a  distance  from  the  base  of  the  brain  and  the  large  ganglia,  and 
if  they  merely  displace  the  brain  filaments  without  destroying  them,  may 
produce  absolutely  no  symptoms  at  all.  This  fact,  which  has  been  ascribed 
to  a  supposed  faculty  of  accommodating  itself  to  pressure  residing  in  the 
brain,  is  better  explained  by  Niemeyer  to  be  due  to  the  atrophy  of  cerebral 
substance  which  takes  place  in  the  neighbourhood  of  slowly  growing- 
tumours,  allowing  of  increase  in  size  of  the  growth  without  interference 
with  cerebral  function.  Sometimes  the  symptoms  are  so  trifling  as  to  be 
overshadowed  by  others  arising  from  disease  or  disturbance  of  a  different 
part  of  the  body.  Again,  after  being  a  long  time  latent,  the  growth  may 
give  rise  to  obstinate  headache,  to  a  slight  squint,  or  some  other  form  of 
muscular  spasm  ;  and  for  weeks  or  months  this  may  be  the  only  symptom 
to  be  detected.  In  cases  where  the  morbid  growth  consists  of  cheesy 
matter  other  symptoms  may  arise  not  due  directly  to  the  cerebral  tumour. 
Thus  the  patient  often  dies  of  a  tubercular  meningitis,  the  symptoms  of 
which  may  quite  conceal  any  special  phenomena  resulting  from  the  tumour 
of  the  brain. 

There  are  no  symptoms  peculiar  to  an  intracranial  growth,  for  all  are 
the  consequence  of  local  destruction  of  substance,  of  pi'essure  on  the  tissue 
around,  and  of  interference  with  its  vascular  supply.     A  distinctive  char- 


332  DISEASE   IlSr   CHILDEEN, 

acter  is,  however,  given  to  the  disease  by  its  course,  the  sequence  of  its 
phenomena,  and  the  predominance  of  some  symptoms  over  others. 

There  are  certain  general  symptoms  which  are  found  in  most  cases  of 
cerebral  tumour.  Headache  is  usually  early  to  occur,  and  may  remain  for 
a  long  time  the  sole  morbid  phenomenon.  Often  slight  at  first,  it  becomes 
gradually  more  intense,  and  may  assume  a  violent  paroxysmal  character 
which  is  infinitely  distressing.  Infants  show  this  by  contracting  the  brows, 
throwing  up  the  hand  to  the  head,  roUing  the  head  from  side  to  side,  and 
occasionally  breaking  out  into  piercing  cries.  An  older  child  will  jDlace 
his  hand  upon  the  site  of  the  pain  if  asked  to  do  so.  He  avoids  the  light ; 
shudders  at  a  loud  noise  ;  and  often  buries  his  face  in  the  pillow  of  his 
bed,  or  covers  his  head  with  the  bedclothes.  The  attacks  of  headache  are 
generally  accompanied  by  vomiting,  and  often  by  dizziness. 

Sooner  or  later  convulsions,  tonic  or  clonic,  may  supervene.  These 
are  sometimes  complete  and  bilateral,  and  resemble  attacks  of  epilepsy. 
Sometimes  they  are  partial,  and  are  confined  to  the  face,  the  eyes,  or  one 
limb.  The  convulsions  may  be  preceded  by  tr^mours  or  twitchings  without 
loss  of  consciousness,  and  it  may  happen  that  these  latter  are  present  with- 
out being  followed  by  more  decided  seizures.  If  attacks  of  such  motor 
disturbance,  of  whatever  degree,  are  noticed  from  time  to  time  in  the  same 
part,  or  persist  in  it,  the  symptom  is  a  very  suspicious  one.  Convulsions 
are  said  to  be  more  common  when  the  growth  is  situated  in  the  posterior 
lobes  of  the  brain,  and  to  be  less  frequent  when  the  anterior  lobes  are 
affected.  If  the  seizures  are  epileptiform  in  character,  the  tumour  is  proba- 
bly in  or  near  the  cortical  substance  of  the  cerebrum. 

The  convulsions  may  be  followed  by  temporary  paralysis  in  the  affected 
muscles,  and  in  some  cases  a  permanent  paralysis  may  be  observed.  This 
more  commonly  affects  muscles  supplied  by  cerebral  nerves  than  is  the 
case  in  other  diseases  of  the  brain.  The  external  rectus  may  be  affected 
(sixth  nerve),  producing  convergent  squint  ;  there  may  be  ptosis,  dilatation 
of  pupil,  and  external  strabismus  from  paralysis  of  the  third  nerve  ;  the 
facial  muscles  may  be  paralysed  ;  and  there  may  be  impairment  of  deglu- 
tition or  articulation.  Sometimes  hemiplegia  is  produced.  The  cerebral 
nerves  are  affected  on  the  same  side  as  the  growth :  the  spinal  nerves  on 
the  opposite  side.  If,  however,  there  be  several  tumours  present  in  the 
brain,  nerves  of  both  sides  may  be  involved,  and  we  may  find  hemiplegia 
combined  with  variously  distributed  paralyses  on  both  sides  of  the  face. 
Generally  the  paralysis  is  developed  slowly,  and  is  preceded  by  pain  in  the 
muscles  about  to  be  affected.  When  it  occurs  suddenly  after  a  convulsive 
seizure,  the  case  is  often  mistaken  for  one  of  cerebral  haemorrhage.  Con- 
tractions often  occur  in  the  paralysed  muscles,  and  may  follow  the  paralysis 
very  rapidly. 

There  is  usually  loss  of  special  sense.  Deafness  may  occur,  and  im- 
pairment of  vision  is  a  frequent  symptom.  Amaurosis  is  said  to  be  most 
common  when  the  growth  occupies  the  anterior  lobes  ;  in  which  case  the 
straight  sinus  is  compressed  and  the  escape  of  blood  obstructed  from  the 
veins  of  the  eje.  Impairment  of  vision  is  not,  however,  confined  to  these 
cases.  It  is  often  seen  when  the  tumour  is  seated  in  the  posterior  lobes  or 
in  the  cerebellum.  The  disturbance  of  sight  is  then  attributed  to  com- 
pression of  the  vena  magna  Galeni  ;  and  the  interference  with  the  circula- 
tion induces  at  the  same  time  a  copious  effusion  into  the  lateral  ven- 
tricles. 

Ophthalmoscopic  examination  of  the  eye  almost  always  shows  impor- 
tant changes  which  affect  the  retina  of  both  eyes.     We  find  that  the  disk 


CEEEBKAL   TUMOUE — SYMPTOMS.  333 

is  swollen  and  blurred  at  the  margins,  with  tortuosity  of  the  central  vein. 
If  the  child  live  long  enough  the  optic  nerve  may  atrophy. 

Unless  chronic  meningitis  become  developed,  or  there  are  numerous 
tumours  in  the  cerebral  substance  of  both  hemispheres,  intelligence  is  but 
little  affected.  Still  the  child  generally  shows  some  change  in  character. 
He  is  fretful  and  perverse,  or  morose  in  temper,  and  gives  much  trouble 
in  the  nursery  and  school-room. 

In  slowly  growing  tumours  the  development  of  the  symptoms  is  very 
gradual.  These  are  the  cases  which  are  comparatively  easy  to  recognise. 
We  find  a  history  of  headache,  of  tremors,  or  convulsive  attacks,  followed 
at  a  longer  or  shorter  interval  by  paral^^sis  more  or  less  complete,  involv- 
ing often  special  senses,  and  implicating  tlie  cerebral  nerves  as  well  as  those 
of  the  spine. 

A  good  illustration  of  the  symptoms  is  seen  in  the  following  case  : 

A  little  boy,  aged  five  years  and  a  half,  who  had  had  a  slight  conver- 
gent squint  since  the  age  of  two  years,  but  had  otherwise  enjoyed  perfect 
health,  began  to  suffer  in  the  month  of  June  from  peculiar  symptoms  of 
illness,  A  short  time  previously  he  had  had  a  severe  fall  upon  his  head. 
The  accident  shook  him  for  a  time,  but  its  effects  appeared  to  pass  off  com- 
pletely. Early  in  June,  however,  the  boy  began  to  complain  of  headache, 
which  came  on  in  severe  paroxysms,  so  that  he  cried  out  with  the  paiD, 
Almost  at  the  same  time  his  limbs  began  to  get  weak.  His  arms  trembled 
when  he  took  anything  up  in  his  hands,  and  he  tottered  as  he  walked. 
Very  soon  afterwards  his  sight  began  to  fail,  and  he  used  to  vomit,  espe- 
cially at  night ;  but  his  other  senses  seemed  perfect,  and  his  intelligence 
was  unimpaired.  After  a  time  the  severity  of  the  headache  diminished, 
but  the  other  symptoms  were  intensified,  so  that  by  November,  when  he 
was  admitted  into  the  East  London  Children's  Hospital,  he  was  almost 
blind  and  had  quite  lost  the  power  of  walking. 

On  admission  (November  16th)  the  muscles  were  well  nourished  and 
seemed  firm,  but  any  voluntary  movement  excited  a  kind  of  spasm,  during 
which  both  arms  were  drawn  up,  seemed  to  get  rigid,  and  were  agitated 
by  a  peculiar  trembling  which  lasted  for  one  or  two  minutes.  The  legs 
also  appeared  very  weak.  When  placed  upon  his  feet  he  could  not  stand 
without  support,  and  when  he  tried  to  do  so  a  tremor  was  noticed  in  the 
legs  like  that  which  affected  the  arms.  There  was  no  paralysis  of  the  face, 
and  the  tongue  was  protruded  in  the  middle  line.  He  had  only  partial 
control  over  his  sphincters,  for  when  he  felt  the  desire  to  evacuate  the 
bowels  or  the  bladder,  he  usually  passed  his  water  or  motions  in  the  bed 
before  there  was  time  for  any  one  to  come  to  his  assistance.  He  was  quite 
blind,  and  an  ophthalmoscopic  examination  showed  the  presence  of  optic 
neuritis.  His  other  senses  were  perfect,  and  his  intelligence  was  quite 
equal  to  that  of  other  children  of  his  age.  His  temperature  at  9  a.m.  was 
102° ;  pulse,  138. 

For  some  days  after  admission  the  boy  continued  in  much  the  same 
state.  The  temperature  remained  between  100°  and  101°,  rather  higher 
at  night  than  in  the  morning.  The  tremors  persisted,  and  the  weakness 
became  more  and  more  marked.  In  about  ten  days,  however,  some  rigidity 
of  the  left  arm  was  noted.  The  elbow  became  slightly  stiff,  and  he  kept 
his  left  hand  tightly  clenched  over  the  inverted  thumb.  He  used  only  the 
right  hand  voluntarily,  although  if  made  to  hold  anything  in  the  left  he 
could  do  so. 

On  November  28th  control  over  the  sphincters  was  quite  lost,  and  he 
passed  his  water  in  the  bed.    The  bowels  were  usually  costive.    There  was 


334  DISEASE  IN   CHILDEEN. 

rigidity  and  tremor  of  both  arms,  the  head  was  retracted,  and  the  back 
was  kept  rigidly  extended.  Still,  intelligence  remained  unimpaired.  Some- 
times the  boy  answered  questions  in  a  sleepy  tone,  but  he  perfectly  under- 
stood all  that  was  said  to  him.  He  made  no  complaints.  Temperature  at 
9  A.M.,  104.6°  ;  pulse,  144.     At  6  p.m.,  temperature,  104.4°  ;  pulse,  148. 

On  November  29th  he  became  very  drowsy  and  would  answer  no  ques- 
tions. Both  arms  were  rigid  and  flexed,  with  the  thumbs  twisted  inwards. 
The  legs  also  had  become  stiff  and  the  toes  extended.  The  back  was  rigid 
with  inclination  to  opisthotonus.  He  could  swallow,  but  apparently  -with 
difficulty.  The  respiration  was  jerking,  and  appeared  to  be  chiefly  dia- 
l^hragmatic.  The  abdomen  was  rather  retracted.  The  eyeballs  twitched. 
The  child  was  alternately  flushed  and  pale,  with  profuse  perspiration.  He 
had  several  conviilsive  attacks  during  which  the  left  corner  of  his  mouth 
was  drawn  up.  Temperature  at  9  a.m.,  108°.  The  boy  had  no  more  fits 
after  2  p.m.,  but  lay  unconscious  with  his  eyes  fixed  and  turned  to  the 
right.  There  was  oscillation  of  the  eyeballs,  and  the  pujDils  were  dilated 
and  immovable.  He  winked  when  the  right  eye  was  touched,  but  the  left 
conjunctiva  was  insensible.  The  joints  were  rigid  and  flexed.  The  belly 
was  retracted.  The  pulse  was  excessively  rapid  and  very  irregular  in  force 
and  rhythm.  Kespiration  36,  with  occasional  deep  sighs.  The  child  died 
the  same  night  in  convulsions.  The  temperature  shortly  before  death  was 
108.8°. 

On  examination  of  the  body  the  brain  weighed  fifty  ounces.  The  con- 
volutions were  flattened,  especially  over  the  right  hemisphere.  On  remov- 
ing a  thin  layer  of  brain-substance  at  the  posterioi-  part  of  this  hemisphere 
a  large  cavity  was  found  of  between  two  and  three  inches  in  diameter.  This 
was  empty  and  was  lined  by  a  species  of  false  membrane.  The  brain-sub- 
stance composing  its  roof  seemed  rather  firmer  than  natm'al,  and  was  from 
one-sixth  to  one -fourth  of  an  inch  in  thickness.  The  floor  of  the  cavity  was 
formed  by  a  firm  lobulated  tumour  as  large  as  a  good-sized  orange.  This 
reached  to  the  base  of  the  skull,  where  it  was  firmly  attached  to  the  dura 
mater.  It  lay  external  to  the  pons,  occupying  the  posterior  part  of  the 
middle  lobe  and  the  adjacent  part  of  the  posterior  lobe.  Its  boundaries 
were  not  distinctly  defined,  for  it  passed  insensibly  into  the  cerebral  sub- 
stance around.  On  section  the  mass  showed  a  uniform  siu'face  of  a  yel- 
lowish-white colour.  It  was  generally  ver}''  firm  to  the  touch,  but  spots  were 
found  here  and  there  where  the  substance  was  softer,  as  if  from  fatty  de- 
generation. Some  of  these  softened  spots  had  become  hollowed  out  into 
cavities  of  about  the  size  of  a  marble,  with  irregular  walls.  On  microscopi- 
cal examination  the  tumour  was  found  to  consist  of  small  round  cells,  with 
many  spindle-shaped  cells  and  a  fibrous  matrix.  There  were  also  many  fat 
globules.  The  lateral  ventricles  contained  about  eight  ounces  of  fluid. 
The  crura  cerebri  were  softened,  flattened,  and  rather  twisted.  The  cor- 
pora quadrigemina  also  softened.  Optic  nerves  small  and  soft.  There  was 
no  appearance  of  recent  meningitis. 

This  case  illustrates  fairly  well  the  course  of  the  disease.  The  severe 
paroxysms  of  headache  with  which  the  illness  began,  the  vomiting,  the 
affection  of  sight,  the  gradually  increasing  paralysis,  and  the  muscular  con- 
tractions and  spasms  which  succeeded,  together  with  the  chronic  j)rogress 
of  the  case,  all  pointed  to  compression  of  the  cerebral  substance.  It  is 
probable  that  the  efiusion  into  the  ventricles  was  a  late  symptom,  only  oc- 
curring when  the  retraction  of  the  head  and  dorsal  rigidity  became  marked. 
The  accumulation  of  fluid  compressed  the  cerebral  substance,  and  was  a 
cause  of  the  drowsiness  and  stupor  which  marked  the  last  hours  of  the 


CEEEBEAL   TUMOUR — SYMPTOMS.  335 

boy's  illness.  The  complete  clearness  of  mincl  whicli  continued  until  a 
late  period  in  tlie  course  of  the  disease  is  worthy  of  note  in  the  case  of  so 
large  a  growth.  A  curious  point  in  the  case  is  the  continuous  elevation  of 
temperature  ;  for  pyrexia  is  not  a  usual  symptom  in  gliomatous  tumours  of 
the  brain  until  quite  the  close  of  the  illness,  unless  the  growth  be  compli- 
cated with  meningitis,  and  in  this  case  no  recent  signs  of  inJflammation 
could  be  discovered.  On  account  of  this  pyrexia  the  tumour  was  thought  to 
be  a  tubercular  one,  although  no  evidence  of  tubercle  could  be  obtained 
during  life  by  examination  of  the  other  organs  of  the  body. 

In  the  case  of  children  it  is  exceptional  to  find  any  other  variety  of  tu- 
mour than  the  tubercular  form.  This,  in  the  majority  of  cases,  becomes 
sooner  or  later  complicated  with  tubercular  meningitis,  the  symptoms  of 
which  will  then  mix  with  and  obscure  the  more  special  phenomena  con- 
nected with  the  cerebral  growth.  Anomalous  cases  of  tubercular  menin- 
gitis are  often,  as  Dr.  Hennis  Green  pointed  out  in  his  admirable  paper, 
instances  of  this  combination. 

A  little  girl,  twelve  months  old,  was  noticed  towards  the  beginning  of 
March  to  squint  outwards  with  the  left  eye,  and  shortly  afterwards  the 
eyelid  of  that  side  began  to  droop.  Much  about  the  same  time  she  suf- 
fered from  sickness,  and  was  restless  and  agitated,  often  screaming  out  as 
if  in  pain.  The  face  used  to  flush,  often  on  one  side  only.  She  took  her 
bottle  well.  The  bowels  were  confined.  At  the  beginning'of  April  the 
restlessness  from  which  she  had  suffered  increased,  and  she  cried  greatly, 
rolling  her  head  from  side  to  side  on  the  pillow.  She  then  had  a  fit  in 
which  both  arms  and  legs  were  rigid  and  convulsed  ;  her  head  was  re- 
tracted and  her  back  arched.  After  this  she  did  not  completely  recover 
consciousness,  and,  either  from  dulness  of  intelligence  or  from  impaired 
vision,  ceased  to  recognise  her  mothei*.  She  still,  however,  took  her  bottle 
well  "when  the  teat  was  put  into  her  mouth. 

When  seen,  on  April  23d,  the  child  lay  in  her  cot  apparently  uncon- 
scious. The  head  was  retracted  and  the  back  rigid ;  the  arms  were  stiff 
a,nd  semiflexed,  with  the  thumbs  inverted  ;  the  big  toes  on  each  side  were 
rigid  and  extended  ;  but  while  the  left  lower  limb  lay  stiff  and  straight 
the  right  was  slightly  flexed,  and  the  leg  from  the  knee  downwards  was  in 
constant  movement,  alternately  flexed  and  extended.  There  was  ptosis  of 
the  left  eye,  but  no  squint.  The  pupils  were  unequal  and  insensible  to 
light,  the  left  the  more  dilated.  The  breathing  was  irregular,  with  sighs 
and  pauses.  Temperature  at  6  p.m.,  99°.  The  child  took  her  bottle  well, 
but  lay  as  if  unconscious,  although  the  pupils  contracted  when  the  con- 
junctivae were  touched.  After  this  the  rigidity  continued  with  occasional 
remissions,  and  an  external  squint  became  again  developed  in  the  left  eye. 
The  temperature  varied  between  99°  and  100.5°. 

At  the  beginning  of  May  the  patient  began  to  cough,  and  a  pneumonic 
consolidation  was  discovered  in  the  right  lung.  After  this  she  became 
rapidly  worse  ;  the  coma  became  deeper  ;  the  temperature  rose  to  103°  ; 
and  she  died  on  May  11th. 

On  examination  of  the  body  there  was  found  a  consolidation  breaking 
down  in  the  right  lung  with  many  gray  granulations.  The  convolutions  of 
the  brain  were  flattened  and  congested.  Its  substance  was  excessively  soft, 
so  that  the  brain  did  not  preserve  its  shape  when  removed.  The  lateral 
ventricles  contained  eight  ounces  of  clear  fluid.  Attached  to  the  under 
surface  of  the  left  crus  cerebri  was  a  nodiilated  tumour  of  the  size  of  a 
walnut,  feeling  soft  to  the  touch  like  a  bag  of  pus.  It  was  irregular  on 
the  surface,  and  was  attached  to  the  crus  by  a  slender  stalk  of  soft,  yellow 


336  DISEASE   ITT   CHILDEEJSr. 

claeesy  matter,  and  covered  with  pia  mater.  No  gray  granulations  could 
be  detected  about  tlie  membranes,  but  the  dura  mater  was  reddened  and 
thickened. 

In  this  case  the  occurrence  of  signs  of  paralysis  of  the  left  third  nerve 
(ptosis  and  external  strabismus),  accompanied  by  headache  and  vomiting, 
pointed  to  localised  pressure,  such  as  that  of  a  grov^th  ;  and  as  this  nei-ve 
and  no  other  was  affected  at  the  first,  the  position  of  the  growth  in  or 
uj)on  the  left  crus  cerebri  (which  is  pierced  by  the  oculo-motor  nerve) 
could  be  positively  indicated.  The  other  symptoms — convulsions,  rigidity, 
and  stupor — -which  followed  after  an  interval  are  such  as  are  common  in 
cases  of  cerebral  tubercle,  and  almost  invariably  attend  the  close  of  the  ill- 
ness. In  fact,  such  sj^mptoms,  preceded  during  several  months  by  head- 
ache, vomiting,  and  pai-alysis  of  a  cerebral  nerve  on  one  side,  are  very 
characteristic  of  tubercle  of  the  brain.  The  disease  might,  indeed,  be 
often  divided  into  two  stages — an  early  chronic  stage,  in  which  headache, 
vomiting,  optic  neui'itis,  tremors  and  convulsive  movements,  and  more  or 
less  marked  muscular  weakness  succeed  one  another  ii-regularly  and  at 
various  intervals  of  time,  and  into  an  acute  second  stage,  in  which  con- 
vulsions, paralysis,  rigidity  of  limbs,  retraction  of  head,  and  stupor  usher 
in  the  end  of  the  illness.  "We  must  not,  however,  always  expect  to  meet 
with  a  division  of  the  disease  into  two  well-defined  stages.  Sometimes 
the  earlier  ccfarse  of  the  malady  is  accompanied  by  few  symptoms,  and 
these,  on  account  of  the  tender  age  of  the  child  and  the  character  of  the 
symptoms  themselves,  may  have  httle  importance  attached  to  them. 

Thus  a  httle  girl,  aged  six  months,  had  vomited  more  or  less  since 
bii'th,  and  was  said  to  moan  fi-equently  and  "  fret "  as  if  in  pain.  She  had 
wasted  considerably  but  had  never  had  convulsions.  The  family  history 
was  a  healthy  one. 

In  so  young  a  child  vomiting,  pain,  and  restlessness,  combined  with 
loss  of  flesh,  are  familiar  symjDtoms,  and  do  not  point  in  any  way  to  intra- 
cranial disease.  But  on  examining  the  baby  carefully  it  was  noticed  that 
when  the  child  cried  the  mouth  was  drawn  up  to  the  left-  side,  and  that 
the  left  eyebrow  contracted  better  than  the  right.  When  the  face  was  at 
rest  the  right  eye  was  more  open  than  the  left,  and  the  nasal  line  skirting 
the  angle  of  the  mouth  was  less  deep  on  the  right  side  of  the  face.  The 
pupils  were  equal  and  there  was  no  sciuint. 

In  a  few  days  other  symptoms  began  to  be  observed.  The  head  became 
retracted,  there  were  tremulous  movements  in  the  right  arm,  the  child 
seemed  heaxj  and  stupid,  and  often  appeared  to  be  quite  unconscious. 
Eigidity  of  the  limbs  then  came  on,  the  drowsiness  deepened  into  coma, 
and  the  child  died.  After  death  patches  of  meningitis  were  found  at  the 
base  of  the  brain.  A  small  cheesy  mass,  the  size  of  a  cheriy-stone,  was 
imbedded  in  the  substance  of  the  pons — the  left  posterior  half — and  a 
second,  pedunculated,  growth  of  the  size  of  a  marble  was  attached  to  the 
uj)per  part  of  the  medulla  oblongata  and  lay  underneath  the  right  crus 
cerebri.  There  was  a  considerable  amount  of  fluid  in  the  ventricles,  and 
a  mass  of  caseous  glands  in  various  stages  of  softening  lay  about  the  roots 
of  the  lungs. 

Sometimes  the  disease  begins  with  extensive  paralysis.  This  was  the 
case  with  a  little  girl,  aged  four  years,  in  whom  the  first  symptoms  noticed 
were  left  hemiplegia  and  vomiting  four  or  five  months  before  her  death. 
In  other  cases  the  onset  of  the  illness  may  be  indicated  by  a  muscular  tre- 
mor or  a  convulsive  attack.  In  the  majority  of  instances,  however,  severe 
headache  precedes  the  other  symptoms. 


CEREBEAL   TUMOUR— SYMPTOMS — DIAGNOSIS.  337 

On  account  of  the  frequency  with  which  tubercle  occupies  the  cerebellum 
in  children  it  is  important  to  be  aware  of  the  phenomena  which  usually 
accompany  a  growth  situated  in  this  region  of  the  brain.  The  characteristic 
group  of  symptoms  consists  of  vomiting,  occipital  headache,  amaurosis, 
and  a  staggering  gait.. 

The  vomiting  is  especially  obstinate.  It  is  a  frequent  accompaniment 
of  all  cerebral  tumours,  but  when  combined  with  occipital  pain  is  ver^^  sug- 
gestive of  a  cerebellar  growth.  The  headache  is  the  consequence  of  pres- 
sure upon  and  stretching  of  the  tentorium.  It  affects  the  occiput  especiallj-, 
and  may  radiate  to  the  back  of  the  neck.  If,  as  sometimes  happens,  it  is 
accompanied  by  rigidity  of  the  muscles  of  the  nucha,  we  find  a  curious  re- 
semblance to  cervical  caries  which  may  be  a  source  of  perplexity.  Amau- 
rosis from  optic  neuritis  is  a  common  symptom  of  this  as  well  as  of  all  other 
forms  of  intracranial  tumours,  but  growths  in  the  cerebellum  are  especially 
apt  to  press  ui^on  the  venous  channels  in  the  neighbourhood  and  impede 
the  escape  of  blood  from  the  retina.  Staggering  gait  is  the  most  charac- 
teristic symptom  of  cerebellar  tumour,  and  when  combined  with  the  preced- 
ing is  sufficient  to  establish  a  diagnosis.  Dr.  Bastian  compares  the  walk 
of  such  patients  to  that  of  one  who  paces  the  deck  in  a  rough  sea.  In  the 
case  of  a  child  it  looks  as  if  the  patient  were  only  now  learning  to  walk, 
and  if  combined,  as  it  often  is,  with  a  certain  stiff  way  of  carrying  the  head, 
the  effect  in  the  elder  children  is  very  curious.  After  a  time  the  weakness 
extends  to  the  limbs,  which  then  become  unable  to  support  the  trunk. 
Tonic  contractions,  too,  may  afi'ect  the  muscles  of  the  back  and  limbs  as 
well  as  those  of  the  nucha,  and  are  sometimes  very  severe.  Tonic  rigidity 
is  much  more  common  than  clonic  convulsions  when  the  tumour  affects  this 
region  of  the  brain.  Dr.  Stephen  Mackenzie  lays  it  down  as  a  general  rule 
that  "tonic  contraction  is  a  product  of  cerebellar,  clonic  of  cerebral  dis- 
ease." These  contractions,  like  the  paresis,  affect  the  muscles  of  the  trunk 
before  those  of  the  limbs. 

The  pons  and  medulla  oblongata  are  also  frequently  visited  by  tuber- 
culous formations.  In  the  former  situation  the  growth  may  produce  neu- 
ralgia, anaesthesia,  or  paralysis  of  the  fifth  nerve,  difficulty  of  deglutition, 
and  disturbance  of  the  function  of  the  bladder.  If  the  growth  occupj'  the 
anterior  lateral  half,  the  third  and  fourth  nerves  may  be  paralysed.  If  it 
lie  in  the  posterior  lateral  half,  there  may  be  paralysis  of  the  fifth  and  facial 
nerves,  and  in  either  case  there  may  be  hemiplegia  of  the  opposite  half  of 
the  body. 

In  the  medulla  oblongata  the  growth  may  produce  wide-spread  mis- 
chief. Extensive  paralysis  is  common  ;  there  may  be  difficulty  of  degluti- 
tion and  articulation  and  incontinence  or  retention  of  urine  from  paralysis. 
of  the  bladder.     Convulsions  are  common  in  these  cases. 

Tuberculous  tumours,  when  they  occur  in  infants,  are  almost  invariably 
a  part  of  a  general  formation  of  tubercle  in  the  body.  They  are  very  apt 
to  be  complicated  with  catari'hal  pneumonia  excited  by  the  presence  of 
the  gray  granulation  in  the  lungs,  and  in  a  large  proportion  of  these  cases,, 
as  has  been  said,  the  illness  closes  with  all  the  signs  of  the  third  stage  of 
tubercular  meningitis.  In  older  children  the  formation  of  tubercle  may- 
not  be  general.  Still,  we  often  find  evidence  of  scrofulous  consolidation 
of  lung,  or  caseous  bronchial  glands,  and  in  such  cases  the  cerebral  mass 
might,  perhaps,  be  more  strictly  described  as  scrofulous  cheesy  matter 
than  true  tubercle.  In  exceptional  cases  no  other  sign  of  disease  is  to  be 
found  in  any  part  of  the  body. 

Diagnosis. — The  existence  of  a  tumour  of  the  brain  can  only  be  ascer- 
22 


338  DISEASE   IIS"   CHILDEEIS". 

tained  by  careful  attention  to  the  course  of  the  ilhaess  and  the  character- 
istic grouping  of  symptoms  to  which  it  gives  rise.  If  the  combination  of 
headache,  vomiting,  and  double  optic  neuritis  be  discovered,  it  is  highly 
probable  that  a  cerebral  gTOwth  is  present ;  but  in  infants,  although  the 
existence  of  headache  and  vomiting  is  easy  to  ascertain,  an  op)hthalmo- 
scopic  examination  of  the  eyes  is  often  a  far  from  easy  matter,  and  even 
the  c[uestion  of  impaii'ment  of  sight  may  be  a  difficult  one  to  decide.  It 
is  probable  that  many  instances  of  supjDOsed  dulness  of  mind  at  this  early 
age  are  really  instances  not  of  imbecihty,  but  of  bHndness.  The  child 
ceases  to  recognise  famihar  faces  because  he  has  ceased  to  see  them.  In 
such  cases  the  test  of  a  bright  hght  passed  before  the  eyes  is  a  veiy  valu- 
able one  ;  for  if  the  eyes  follow  the  light  the  infant  is  evidently  not  un- 
conscious, and  the  retina  is  usually  still  capable  of  appreciating  a  lumi- 
nous jet,  although  its  sensitiveness  to  ordinary  objectsis  impaii-ed.  If  then, 
in  an  infant  who  is  subject  to  headache  and  vomiting,  we  can  ascertain  in 
addition  that  the  sight  has  failed,  we  have  gone  far  to  establish  the  exist- 
ence of  tumour.  If  now  a  local  paralysis  arise,  or  tremors  or  conMolsive 
spasms  are  noted  in  special  muscles,  we  may  feel  satisfied  that  our  diag- 
nosis is  a  correct  one. 

If  a  young  child  is  seen  first  towards  the  close  of  the  disease  when  the 
symptoms  have  become  complicated  with  those  of  basilar  meningitis,  we 
must  incjuire  carefully  as  to  the  previous  coui'se  of  the  illness  and  the 
progression  of  the  symptoms.  If  we  find  a  history  of  chronic  disease  in 
which  headache,  sickness,  and  local  paralysis,  such  as  squinting,  ptosis,  or 
distortion  of  the  face,  have  occurred  some  months  previously  ;  if  any  loss 
of  "i^ower  observed  has  been  persistent ;  and  esj^ecially  if  we  can  discover 
that  the  child  is  the  subject  of  optic  neuritis,  or  that  his  sight  has  been 
faihng,  we  may  give  a  positive  opinion  that  a  tumour  is  present  in  the 
brain.  Even  the  anomalous  course  of  a  tubercular  meningitis  is  suspicious 
of  a  cerebral  growth,  and  the  sudden  appearance  of  symptoms  character- 
istic of  the  third  stage  of  this  disease  (con"\Tilsions,  stupor,  scpinting,  un- 
equal pupils,  paralysis,  or  rigidity  of  joints),  jDreceded  by  signs  of  chronic 
nervous  distui'bance,  are  veiy  suggestive  of  tubercle  of  the  brain. 

In  older  children  the  combination  of  headache,  vomiting,  and  optic 
nem*itis  is  very  significant  if  Bright's  disease  can  be  excluded.  Severe 
headache  alone  is  of  no  value,  for  migraine  is  a  not  uncommon  complaint 
in  young  persons.  The  disease  does  not,  however,  always  begin  with  pain 
in  the  head.  ^Tien  this  symptom  is  absent,  tremors  or  muscular-  spasms 
occurring  repeatedly  in  the  same  limb  or  the  same  region  of  the  body  are 
suspicious.  If  after  a  time  they  become  more  severe  and  general,  and  are 
complicated  with  other  signs  of  nervous  distui'bance,  such  as  paralysis, 
especially  of  a  cerebral  nerve,  and  impairment  of  sight,  the  disease  is  in 
aU  probability  tumour  of  the  brain. 

The  actual  position  of  the  new  formation  can  seldom  be  more  than 
suspected.  In  the  case  of  a  cerebellar  growth,  the  symptoms  to  which 
this  gives  rise  have  been  abeady  described.  When  the  tumour  occupies 
the  base  of  the  brain,  paralysis  of  some  special  cerebral  nerves  may  reveal 
the  seat  of  pressure.  In  other  parts  of  the  brain  the  symptoms  are  so 
often  contradictory,  and  are  so  liable  to  be  altered  and  confused  by  dis- 
turbing causes,  that  the  situation  of  the  tumoui'  can  seldom  be  predicted 
with  anything  approaching  to  certainty. 

If  epileptiform  attacks  form  part  of  the  symptoms,  these  are  distin- 
guished from  genuine  epilepsy  by  remarking  that  between  the  attacks  the 
j)atient  is  not  well,  but  still  continues  to  exhibit  signs  of  cerebral  irritation. 


CEKEBEAL   TUM0T7E — DIAGNOSIS — PEOGNOSIS.  339 

With  regard  to  the  nature  of  the  growth  :  A  tumour  of  the  brain  is  in 
childhood  so  generally  tubercular  that  we  may  conclude  it  to  be  so  unless 
there  be  signs  to  make  us  suspect  the  contrary.  If,  however,  the  child  be 
■well  nourished  and  of  stui-dy  build,  if  there  be  no  history  of  phthisis  in 
the  family,  and  if  the  other  organs  aj)pear  to  be  healthy,  we  should  hesi- 
tate to  class  the  growth  as  a  tubercular  one.  Children  with  tubercle  of 
the  brain  are  not  necessarily  wasted,  nor  have  they  always  a  tubercular  or 
phthisical  history  ;  but  they  are  usuaUy  pale  and  flabby,  and  generall}^  show 
in  their  physical  conformation  signs  of  diathetic  influence.  No  argument 
can  be  founded  upon  the  age  of  the  child,  for  although  the  disease  is  said 
to  be  rare  under  the  age  of  two  years,  I  cannot  agree  with  this  statement. 
Indeed,  in  the  preceding  pages  I  have  referred  to  two  cases — one  a  little 
girl  of  twelve  months  and  another  aged  six  months,  both  patients  of  my 
own  in  the  East  London  ChUdreu's  Hospital — in  each  of  whom  tubercular 
masses  were  found  after  death  connected  with  the  brain. 

Prognosis. — The  disease  is  so  fatal  a  one  that  when  we  are  satisfied  of 
the  existence  of  a  tumour  of  the  brain,  we  can  have  httle  expectation  of 
the  child's  recovery.  In  very  rare  cases  shrinking  and  calcification  of  a 
tuberculous  tumour  have  been  known  to  occur  ;  but  if  the  growth  has 
produced  symptoms  of  pressure  and  irritation,  little  hope  can  be  enter- 
tained of  a  favoui-able  ending  to  the  illness.  Even  in  cases  where  the 
symptoms,  although  distinct,  are  of  a  mild  character,  we  must  not  aUow 
oui'selves  to  anticipate  necessarily  a  lengthened  course  to  the  disease,  for 
however  chronic  may  have  been  the  earher  symptoms,  the  disease  may  at 
any  time  take  on  a  more  acute  course  and  run  raj^idly  to  a  close. 

Treatment. — In  the  treatment  of  these  cases  we  must  attend  to  the  con- 
stitutional condition  of  the  child  and  correct  any  derangement  which  may 
be  present  to  interfere  with  the  nutritive  processes.  We  must  remedy 
any  digestive  disturbance  and  regiilate  the  bowels.  By  imj^roving  the 
general  health  of  the  patient  we  may  perhaps  help  to  arrest  the  extension 
of  the  mass,  and  may  possibly  promote  the  calcification  of  the  tumoui'. 
The  child  should  Hve,  if  possible,  in  a  dry  bracing  air  ;  should  be  warmly 
clothed,  judiciously  fed,  properly  exercised,  and  be  treated  generally  ac- 
cording to  the  rides  laid  down  for  the  management  of  the  scrofulous  dia- 
thesis. Cod-liver  oil  and  iodide  of  iron  are  useful  aids  to  this  treatment. 
If  any  history  of  syphilis  can  be  obtained,  mercurial  treatment  must  be 
adopted  without  loss  of  time,  and  a  long  course  of  perchloride  of  mercury 
should  be  entered  upon.  Distressing  symptoms  must  be  treated  as  they 
arise.  Vomiting  can  be  often  allayed  by  keeping  the  child  jDerfectly  Cjuiet 
in  a  recumbent  position,  and  by  apj)]ying  an  ice-bag  to  the  head.  Cold 
applications  will  also  reheve  the  headache  when  this  becomes  severe,  and 
a  good  aperient  of  calomel  and  jalap  is  useful.  If  necessary,  morphia  can 
be  given  with  the  same  object. 


CHAPTEE   XII. 

CHROXIC   HYDROCEPHALUS. 

HxDKOCEPHALrs  IS  a  name  given  to  serous  effusions  into  the  cavity  of  the 
skull,  wherever  situated.  The  effusion  may  be  acute  or  chronic.  Acute 
hydi'ocephalus  is  generally  the  consecjuence  of  tubercular  inflammation  of 
the  meninges  of  the  brain,  and  the  name  is  practically  synonymous  with 
tubercular  meningitis — a  disease  which  is  discussed  in  a  separate  chapter. 
It  is  not,  however,  very  uncommon  in  cases  of  death  fi'om  severe  and  pro- 
tracted con^Tilsions,  occui-ring  without  discoverable  organic  lesion  of  the 
nervous  centres,  to  find  collections  of  serosity  in  the  cerebral  ventricles 
and  at  the  base  of  the  brain.  This  effusion  is  accompanied  by  turgescence 
of  the  veins  of  the  pia  mater — itself  probably  a  consequence  of  the  convul- 
sive seizures — and  may  be  looked  upon  as  a  result  of  the  venous  conges- 
tion. This  may  be  considered  an  instance  of  the  non -tubercular  form  of 
acute  hydrocephalus.  Such  a  case  is  narrated  in  the  chapter  on  "Convul- 
sions." 

Chronic  hydrocephalus  is  called  either  internal  or  external,  according 
to  the  situation  of  the  fluid.  In  the  internal  form  the  fluid  is  contained  in 
the  cerebral  ventricles  ;  in  the  external  variety  it  collects  in  the  arachnoid 
cavity.  The  disease  may  be  congenital,  or  may  be  developed  at  some 
period  after  birth.  Hence  there  are  two  chief  divisions  of  cln-onic  hydro- 
cephalus into  the  congenital  and  acquired  variety.  The  congenital  form 
is  usually  an  internal  hydrocephalus,  for  the  fluid  is  for  the  most  part  in 
the  ventricles.  In  the  acqmred  variety  it  may  be  either  internal  or  ex- 
ternal, or  the  fluid  may  collect  in  both  situations. 

Causation. — It  is  difficult  to  say  what  may  be  the  causes  of  congenital 
hydrocephalus,  although  these  are  probably  more  than  merely  temporary 
agencies  ;  for  a  woman  who  has  once  given  buih  to  a  hydrocephahc  infant 
may  do  so  again  in  future  pregnancies.  The  tendency  appears  to  be  often 
hereditaiy,  and  it  has  been  attributed  with  a  doubtful  amount  of  probabihty 
to  drunkenness  and  other  constitutional  vices  on  the  part  of  the  parents. 
According  to  Dr.  B.  Eennert,  of  Frankfort,  the  children  of  workers  in  lead 
who  have  themselves  suffered  from  chronic  lead-poisoning  are  veiy  apt  to 
develope  chronic  hydi'ocephalus.  Sometimes  it  is  associated  with  malfor- 
mation of  the  brain,  for  if  there  is  congenital  atrojohy  of  any  part  of  the 
organ  fluid  is  thrown  out  to  fill  up  the  resulting  space.  This  has  been 
called  '-hydrocephalus  a  vacuo."  Eokitansky  attributes  the  large  majoiity 
of  cases  of  the  congenital  form  of  the  malady  to  inflammation  of  the  arach- 
noid lining  of  the  ventricles  occinTing  during  foetal  life  or  attacking  the 
infant  shortly  after  biiih. 

Acquired  hydrocephalus  usually  occurs  before  the  end  of  the  third 
year.  It  may  be  induced  by  anj'  cause  which  interferes  with  the  cerebral 
circulation,  such  as  tumours  pressing  upon  the  vense  Galeni  or  straight 
sinus,  and  so  impeding  the  escape  of  blood  from  the  ventricles.     Serious 


CHEONIC   HYDEOCEPHALUS — MOEBID   ANATOMY.  341 

pressure  upon  the  veins  of  the  neck  by  enlarged  glands  may  produce  the 
same  result.  So  also  the  intracranial  effusion  may  be  a  part  of  general 
dropsy  dependent  upon  disease  of  the  heart. 

Another  group  of  causes  are  those  which  modify  the  quality  of  the 
blood.  Thus  it  may  occur  as  a  consequence  of  aneemia,  rickets,  and 
other  diseases  which  are  accompanied  by  impoverishment  of  the  blood, 
and  as  a  sequel  of  exhausting  acute  illness.  In  Bright's  disease  hydro- 
cephalus may  be  a  part  of  the  general  dropsy  induced  by  the  state  of  the 
kidney.  The  fluid  in  acquired  hydrocephalus  is  usually  in  the  ventri- 
cles. In  the  rare  cases  where  it  is  found  external  to  the  brain  it  is  some- 
times a  consequence  of  meningeal  hsemorrhage.  In  the  chapter  on  this 
subject  it  was  stated  that  an  arachnoid  clot  becomes  after  a  time,  if  the 
child  survive,  converted  into  a  cyst  by  the  adhesion  of  the  edges  of  the 
layer  of  fibrine — left  after  absorption  of  the  colouring  matter  of  the  blood 
— to  the  serous  membrane.  This  false  membrane,  according  to  Legendre, 
Killiet,  and  others,  is  formed,  as  above  described,  directly  out  of  the  blood- 
clot.  Virchow,  on  the  contrary,  is  of  opinion  that  it  results  from  an  in- 
flammation of  the  internal  surface  of  the  dura  mater,  and  that  the  exuded 
lymph  arising  from  this  process  becomes  vascularised  and  forms  a  pseudo- 
serous  membrane  which  is  the  wall  of  the  cyst. 

The  cyst  may  be  simple  or  loculated,  and  its  contents  consist  of  red- 
dish serum  with  small  clots  and  flocculent  matters.  Often  the  cyst  is 
double,  each  half  corresponding  to  one  of  the  hemispheres  of  the  brain. 
Its  walls  become  thin  and  transparent,  and  have  a  serous  appearance. 
Usually  arborescent  vessels  may  be  seen  to  ramify  on  the  surface.  The 
fluid  contents  become  increased  in  quantity  after  a  time, 'and  may  vary 
from  a  few  spooafuls  to  half  a  pint  or  more. 

Morbid  Anatomy. — When  the  hydrocephalus  is  congenital  and  the  fluid 
accumulates  in  the  ventricles  of  the  brain,  it  tends  to  press  outwards  the 
walls  of  those  chambers.  As  a  consequence  the  brain-substance  is  thinned ; 
the  convolutions  are  flattened,  and,  as  the  pi'essure  is  equal  in  all  direc- 
tions, the  corpora  striata  and  optic  thalami  are  flattened,  separated,  and 
pressed  aside ;  the  septum  lucidum  is  softened,  stretched,  and  often  torn  ; 
the  ventricles  communicate  freely  through  the  dilated  foramen  of  Monro, 
and  the  corpora  quadrigemina,  the  cerebellum,  and  the  pons  are  flattened 
and  compressed.  The  membrane  lining  the  ventricles  is  often  found 
thickened  and  softened,  and  may  be  roughened  or  even  distinctly  granu- 
lar. In  some  cases  the  foramen  of  Majendie  is  closed.  If  the  effusion  is 
large  the  walls  of  the  skull  also  feel  the  effects  of  pressure.  The  head 
becomes  distended ;  the  frontal  bone  is  pushed  forwards ;  the  roofs  of  the 
orbits  are  depressed  so  as  to  flatten  the  sockets  of  the  eyeballs,  and  the 
occij)ital  bone  and  the  squamous  portion  of  the  temporal  bone  are  made 
almost  horizontal.  The  sutures  are  widened  and  the  enlarged  fontanelles 
communicate  by  the  sagittal  suture.  The  shape  of  the  head  is  often  not 
quite  symmetrical,  neither  is  it  globular.  The  curve  is  much  greater  at 
the  sides,  and  the  skull  is  rather  flattened  at  the  vertex.  Ossification  in 
the  cranial  bones  is  delayed,  and  is  said  to  be  often  aided  by  the  conjunc- 
tion of  small  islets  of  bone  formed  in  the  membranous  interspaces.  At  a 
later  stage  the  bones  become  very  thick  and  the  skull  is  remarkably  spher- 
ical in  shape. 

If  no  great  quantity  of  fluid  is  present  the  size  of  the  head  is  not  m- 
ci-eased,  but  this  is  comparatively  seldom  the  case  ;  usually  the  skull  is 
distended  as  described.  The  fluid  is  clear  or  slightly  turbid,  and  varies  in 
quantity  from  a  few  ounces  to  several  pounds.     It  is  of  higher  specific 


342  DISEASE   IIS"   CHILDREN. 

gravity  than  tlie  cerebro-spinal  fluid  ;  is  alkaline  in  reaction,  and  contains 
a  very  feeble  proportion  of  albumen,  besides  chloride  of  sodium  and  urea. 

Various  abnormalities  of  the  cerebrum  may  be  present  from  arrests  of 
development,  and  sometimes  traces  of  old  disease  can  be  discovered,  such 
as  patches  of  sclerosis  resulting  from  past  hsemorrhage  or  inflammation. 
The  cerebral  substance  generally  may  be  of  normal  consistence,  or  anaemic, 
or  cedematous.  Congenital  hydrocephalus  is  often  combined  with  other 
arrests  of  development,  such  as  cardiac  maKormations,  spina  bifida,  hare- 
lip, etc. 

In  acquired  hydrocephalus  the  changes  above  described  stop  short  of 
the  extreme  degree  often  reached  when  the  disease  is  congenital.  The 
ventricles  are  still  dilated,  but  to  a  less  extent.  They  contain  several 
ounces  of  fluid  (six,  eight,  ten,  or  twelve),  usually  limpid  and  clear.  The 
ependym.a  of  the  ventricles  is  thickened  and  often  dotted  over  with  fine 
nodules,  especially  upon  the  optic  thalami,  the  fornix,  and  the  stria  cornea. 
The  choroid  plexus  is  congested,  and  the  brain-substance  may  be  denser  or 
tougher  than  natural. 

If  the  fluid  is  in  the  arachnoid  space  it  is  spread  more  or  less  over  the 
surface  of  the  brain.  The  brain  is  often  cedematous,  and  its  consistence 
is  reduced.  In  extreme  cases  it  may  be  converted  into  a  white  pulp  (hy- 
drocephalic softening). 

Symptoms. — Many  cases  of  congenital  hydrocephalus  which  reach  the 
full  period  of  gestation  die  during  delivery  or  shortly  afterwards.  Others 
survive  for  a  variable  period,  but  they  die  in  the  majority  of  cases  before 
the  end  of  the  second  year.  In  rarer  instances  the  patient  may  live  for 
five  or  ten  years,  or  longer,  and  it  is  said  may  even. reach  extreme  old  age. 

At  birth  the  size  of  the  head  is  not  always  remarkable.  The  appear- 
ance of  the  new-born  infant  may  be  natural,  and  no  cranial  enlargement 
may  be  observed  until  after  the  lapse  of  some  weeks.  Most  cases  of  hy- 
drocephalus present  both  j^hysical  and  mental  peculiarities.  The  head  of 
the  child  becomes  very  large,  but  his  general  develojoment  is  strikingly 
backward.  The  increase  in  size  of  the  skull  is  gradual  and  progressive, 
and  in  some  cases  the  volume  of  the  head  becomes  enormous.  The  pecu- 
liar shape  of  the  skull  and  the  strange  contrast  between  the  dimensions  of 
the  cranium  and  the  little  pinched  and  pointed  face  beneath  it  is  very 
striking  and  characteristic.  In  a  well-marked  case  the  large  globular 
head,  greatly  expanded  at  the  sides  and  flattened  at  the  crovvm,  combined 
with  the  small  face,  if  represented  merely  in  outline  upon  paper,  would 
give  the  impression  of  a  large  oriental  turban  placed  upon  the  head  of  a 
child  of  ordinary  size.  The  skin  over  the  cranium  is  thin  and  seems 
stretched  ;  the  veins  are  full ;  the  hair  is  scattered  and  meagre.  On  placing 
the  hand  upon  the  head  the  large  fontaneUes,  the  widely  opened  sutures, 
and  the  thin,  yielding  bones  convej^  almost  the  impression  of  a  tense  bag 
of  fluid.  Often  fluctuation  can  be  detected,  and  the  soft  parts  may  have 
a  slight  pulsation,  rhythmical  with  the  breathing,  falling  in  (furing  inspi- 
ration and  dilating  again  as  the  breath  is  expired.  The  face  is  thin,  the 
cheeks  are  often  hollow,  and  the  chin  is  small  and  pointed.  The  eyeballs 
are  forced  forwards  by  the  flattening  of  the  roofs  of  their  sockets,  and  at 
the  same  time  the  eyebrows  and  ej'^elids  are  drawn  upwards  by  the  tension 
of  the  skin.  Consequently  the  eyes  look  prominent.  They  appear  also 
to  be  directed  downwards,  for  there  is  a  rim  of  white  above  the  cornea 
from  uncovering  of  the  sclerotic,  while  the  lower  half  of  the  pupil  is  cov- 
ered by  the  lower  eyelid.  This  large  head  is  necessarily  a  heavy  one,  so 
that  the  child  has  a  difficulty  in  supporting  it.     As  the  general  nutrition 


CHROlSriC   HYDROCEPHALUS — SYMPTOMS.  343 

is  imperfect,  and  the  muscular  development  of  the  patient  far  below  a 
normal  standard,  the  difficulty  is  often  great.  The  child  may  endeavour  to 
support  the  head  with  his  hand,  but  often  he  has  to  abandon  the  attempt 
to  keep  himself  upright,  and  is  forced  to  rest  his  head  on  a  pillow  or  on 
his  mother's  lap.  The  weight  of  the  head  is  one  reason  why  these  chil- 
dren are  slow  in  learning  to  walk.  Another  cause  is  the  imperfect  state  of 
nutrition  of  the  body  generally.  Although  the  child  as  a  rule  takes  food 
greedily  and  appears  to  digest  it,  he  does  not  thrive.  His  head  gets  bigger 
and  bigger,  but  the  muscles  of  the  trunk  and  Umbs  remain  feeble,  flablDy, 
and  thin,  and  seem  to  derive  no  benefit  from  his  copious  meals. 

The  intelligence  of  hydrocephahc  jDatients  varies  greatly  in  different 
cases.  Sometimes  it  appears  to  be  unaffected,  and  mental  development 
continues  in  normal  progression.  As  a  rule,  however,  the  child  is  back- 
ward. He  is  slow  to  take  notice,  apathetic,  and  dull  at  an  age  when  other 
infants  can  be  easily  amused.  The  time  for  walldng  arrives,  but  he  makes 
no  effort  to  "feel  his  feet,"  and  if  held  upon  the  ground  allows  his  limbs 
to  double  up  helplessly  underneath  his  body.  When  at  last  he  learns  to 
walk  his  gait  is  tottering  and  uncertain.  This  backwardness  in  locomo- 
tion appears  to  be  partially  due  in  many  cases  to  want  of  intelligence,  but 
the  general  muscular  weakness  and  the  weight  of  the  head  contribute,  no 
doubt,  greatly  to  the  deficiency. 

It  is  very  difficult  to  ascertain  the  degree  of  keenness  of  the  senses  in 
infants.  Hydrocephalic  babies  are  often  thought  to  be  deaf,  but  this  is- 
probably  due  in  many  cases  to  want  of  attention.  The  sight  is  often  im- 
paired, and — as  in  many  other  cerebral  diseases  of  infants — the  child  may 
not  take  notice  of  faces  and  objects  because  he  sees  them  indistinctly. 
Dr.  Clifford  Allbutt  beheves  ischaemia  papillae  to  be  the  earliest  change, 
but  states  that  soon  the  disks  and  retinas  become  wholly  disorganised  and 
the  optic  nerve  is  atrophied  from  pressure.  The  ophthalmoscope  shows  the 
disks  atrophied,  their  outlines  blurred  or  lost,  the  vessels  distorted  or 
closed,  and  the  retina  maculated  with  patches  and  streaks  of  a  brownish 
or  whitish  colour  from  old  haemorrhages,  exudations,  and  fatty  degener- 
ations. Nystagmus  is  a  common  symptom  in  these  cases,  and  there  is 
often  a  convergent  squint. 

Nervous  symptoms  are  seldom  absent.  The  patient  may  be  distressed 
by  attacks  of  laryngismus  stridulus,  and  Dr.  West  has  observed  spasmodic 
dyspnoea.  Convulsions  are  not  rare,  and  sometimes  recur  at  short  intervals. 
So  also  partial  paralyses,  contractions,  and  automatic  movements  may  be 
features  of  the  disease.  There  may  be  also  diminished  sensibility  of  the 
skin,  and  occasionally  the  opposite  condition — hyperaesthesia — has  been 
noticed.  These  children  appear  to  suffer  from  frequent  cephalalgia.  The 
pressing  of  the  head  into  the  pillow  and  the  frequent  rolhug  of  the  head 
from  side  to  side  as  the  infant  lies  in  his  cot  are  almost  invariably  symp- 
toms of  uneasiness  within  the  skull,  and  these  are  seldom  absent  in  hydro- 
cephalic cases.     Sometimes  the  head  is  retracted. 

As  an  example  of  an  ordinary  case  of  chronic  hydrocephalus  I  may  in- 
stance a  little  girl,  aged  two  years  and  a  half,  who  was  admitted  under  my 
care  into  the  East  London  Children's  Hospital.  The  child  was  of  small 
size  except  her  head,  and  weighed  eighteen  j)Ounds  six  ounces.  The 
head  had  been  noticed  to  be  big  from  the  age  of  three  months,  and  had 
been  constantly  growing  larger.  The  patient  had  been  subject  to  convul- 
sions ever  since  birth.  She  could  not  stand  or  support  her  head.  The 
skull  at  the  level  of  the  bosses  of  the  temporal  bones  measured  twenty-two 
inches  in  circumference.     The  fontanelles  were  very  large  and  tense,  and 


344  DISEASE  I]sr   CHILDEEN. 

the  sutures  were  widely  open.  There  was  slight  retraction  of  the  head, 
with  some  rigidity  of  the  muscles  at  the  back  of  the  neck.  The  wrists  and 
elbows  of  both  upper  extremities  were  kept  constantly  flexed,  and  the 
thumbs  were  inverted.  There  were  no  actual  convulsions,  but  the  child 
often  twitched  all  over.  She  was  very  dull  and  stupid,  but  could  be  made 
to  look  round  by  calling  to  her.  She  was  not  blind  ;  but  there  was  nys- 
tagmus, and  squint  was  often  noticed.     Her  temperature  was  normal. 

The  duration  of  the  disease  varies.  Many  patients  die  during  the  first 
year  of  life,  and  comparatively  few  survive  to  the  second.  Still  death  does 
not  always  take  place  so  early.  Sometimes  a  sudden  arrest  occurs  in  the 
disease.  The  head  then  ceases  to  enlarge,  ossification  goes  on  slowly,  and 
general  nutrition  improves.  In  these  cases  it  is  often  long  before  bony 
union  is  completed  in  the  skull.  In  the  case  of  Cardinal,  recorded  by 
Dr.  Bright,  who  hved  with  an  enormous  skull  to  the  age  of  thirty  years, 
ossification  was  not  completed  until  two  years  before  the  patient  died. 

In  acquired  hydi'ocephalus  the  sjmiptoms  are  much  the  same  as  those 
described  in  the  congenital  form,  so  long  as  the  effusion  occurs  before 
consolidation  of  the  skull  is  completed.  If,  however,  it  takes  place  after 
the  fontanelle  is  closed,  the  symptoms  are  obscure,  for  there  are  no  exter- 
nal signs  of  distention.  The  child  generally  becomes  dull  and  hea"\y. 
There  is  headache,  vertigo,  and  often  an  a^^parent  difficulty  in  supporting 
the  head,  so  that  the  patient  lies  about  and  seems  to  dislike  movement. 
If  made  to  walk,  he  totters  and  stej)S  cautiously.  Twitching  or  convulsive 
movements  may  come  on,  the  pupils  get  sluggish  and  dilated,  and  the 
pulse  slow.     Then  the  stupor  deepens  into  coma  and  the  child  dies. 

In  rare  cases  the  symptoms  may  be  relieved  by  spontaneous  evacuation 
of  the  fluid.  Mr.  L.  W.  Sedgwick  has  recorded  such  a  case.  A  little 
hoj,  two  years  of  age,  two  of  whose  brothers  had  died  of  the  disease,  and 
who  had  always  himself  had  a  large  head,  began  to  be  listless  and  dull. 
He  often  complained  of  headache  and  wanted  to  lie  down.  He  slept 
badly  at  night  and  often  woke  uj)  with  a  scream.  After  a  time  his  head 
was  noticed  to  be  growing  larger ;  the  fontanelle  became  very  wide  ;  the 
pupils  were  dilated  and  sluggish,  and  there  was  some  insensibility  to  ex- 
ternal impressions.  The  respirations,  too,  became  slower  and  the  breathing- 
was  oppressed,  While  in  this  state,  the  case  appearing  every  day  to  be 
more  hopeless,  a  sudden  change  was  noticed  for  the  better. .  The  patient  be- 
came brighter ;  his  drowsiness  cleared  off ;  his  pupils  began  again  to  re- 
spond to  light ;  and  he  ceased  to  complain  of  his  head.  This  improvement 
coincided  with  a  copious  flow  of  watery  fluid  from  the  nose  ;  and  after  a 
large  quantity  of  fluid  had  thus  escaped  all  the  unfavourable  symptoms 
disappeared.  Twelve  months  afterwards  they  returned,  and  increased  to 
a  degree  that  seemed  to  render  the  child's  recovery  out  of  the  question ; 
but  again  they  were  relieved  in  a  precisely  similar  manner.  A  case  of  the 
same  kind,  is  recorded  by  Mr.  Barron  in  which  a  large  quantity  of  watery 
fluid  mixed  with  blood  was  discharged  fi'om  the  nose  and  mouth.  In  this 
instance  the  patient  died,  and  on  examination  of  the  skull,  a  narrow  pas- 
sage was  found  conducting  from  the  cranium  to  the  nose  through  the  eth- 
moid bone. 

Although  the  disease  may  become  arrested,  and  in  children  who  survive 
the  accumulation  of  fluid  always  becomes  stationary  after  a  time,  the  usual 
termination  is  in  death.  Such  children,  with  their  weakly  frames  and  feeble 
resisting  power,  fall  easy  victims  to  any  intercurrent  disease  ;  and,  as  a  rule, 
succumb  to  an  attack  of  bronchitis,  pneumonia,  or  severe  intestinal  catarrh, 
even  if  they  do  not  die  from  actual  interference  with  cerebral  function. 


CHEONIC   HYDEOCEPHALUS — DIAGNOSIS — TREATMENT.       345 

Diagnosis. — Mere  enlargement  of  the  head  is  no  proof  in  itself  of  tlie 
existence  of  hydrocephalus  unless  other  symjDtoms  of  fluid  are  present. 
Tn  rickets  the  head  is  often  large,  and  sometimes  this  increase  in  size  is 
due  to  actual  hypertrophy  of  the  brain.  In  syphihs  it  may  be  also  large 
from  extreme  thickening  of  the  cranial  bones.  In  both  of  these  cases, 
however,  a  certain  excess  of  fluid  may  be  eifused,  although  the  quantity 
may  be  insufficient  to  j^roduce  any  iU  effects  from  pressure.  Still,  unless 
actual  intra-cranial  di-oi3sy  be  present,  we  never  see  the  pecuhar  globular 
shape  of  the  skull  which  is  met  vnth.  in  chronic  hydrocephalus.  The 
characteristic  features  of  this  condition  have  ah-eady  been  sufficiently  de- 
scribed. 

In  cases  of  acquired  hydrocephalus,  when  the  collection  of  fluid  takes 
place  after  closure  of  the  fontanelle,  diagnosis  is  very  difficult.  The  con- 
dition is  usually  dependent  upon  a  tumour  of  the  brain  compressing  the 
veins  of  Galen.  It  may  be  susj)ected  when  symptoms  of  gradually  increas- 
ing pressure  upon  the  brain  are  noticed,  and  absence  of  the  more  special 
phenomena  peculiar  to  the  inflammatory  forms  of  cerebral  disease  throws 
us  back  upon  this  as  the  most  likely  cause  of  the  symjptoms.  The  seat  of 
the  fluid  effusion  is  often  difficult  to  ascertain  -^-ith  any  precision,  but  it 
must  be  remembered  that  internal  or  ventricular  hydrocephalus  is  more 
common  than  the  external  variety.  Mr.  Prescott  Hewitt  states  that  the 
flattening  of  the  orbital  plates,  which  forces  forwards  the  eyeballs,  occurs 
only  in  the  internal  form.  If,  then,  in  any  case  the  eyeballs  are  prominent, 
and  we  see  the  lower  half  of  the  pupil  covered  by  the  lower  eyelid,  while 
a  rim  of  white  is  seen  above  the  cornea,  we  may  conclude  that  the  dropsy 
is  ventricular. 

Prognosis. — So  few  children,  comparatively,  survive  the  second  year 
that  the  prognosis  in  intracranial  dropsy  is  always  very  serious.  Congeni- 
tal cases  mostly  die,  and  in  no  instance  can  we  give  a  favourable  oj)inion 
unless  evidences  of  aiTest  of  the  disease  have  become  unmistakable.  Cer- 
tainly in  no  case  can  we  venture  to  hope  for  so  favourable  a  termination  as 
a  spontaneous  evacuation  of  the  fluid.  Even  if  the  disease  become  ar- 
rested, the  patient  remains  in  most  cases  with  a  large  unsightly  head  and 
a  more  or  less  blunted  intelligence.  Con-sTilsions,  twitchings,  retraction  of 
the  head,  and  other  signs  of  cerebral  irritation  are  unfavourable  symptoms. 
So,  also,  are  continued  wasting  and  looseness  of  the  bowels.  If  the  patient 
is  weak,  any  intercuiTent  disease  generally  proves  fatal. 

Treatment. — Cases  of  chronic  hydi'ocephahis  are  the  despair  of  the  physi- 
cian. He  can  do  little  more  than  attend  to  the  general  health  of  the  child, 
regulate  his  bowels,  and  exercise  a  judicious  superAision  over  his  dietary. 
As  regards  arresting  the  disease,  or  causing  absorption  of  fluid  ah-eady  ac- 
cumulated, treatment  appears  to  be  of  slight  value.  I  have  thought  that 
the  persevering  employment  of  perchloride  of  mercury  has  been  of  service, 
for  I  have  found  arrest  of  the  disease  to  occur  in  one  or  two  instances 
while  the  drug  was  being  given,  but  the  same  treatment  has  failed  in  so 
many  other  cases  that  the  more  favourable  resiilt  was  in  all  probability  a 
mere  coincidence.  I  have  never  seen  special  benefit  derived  from  diuretics 
or  tonics,  blisters,  strapping,  or  artificial  evacuation  of  the  fluid.  I  have 
several  times  punctured  the  fontanelle  half  an  inch  to  one  side  of  the 
median  line,  and  after  withdrawing  a  quantity  of  fluid  have  strapped  up 
the  head  tightly  with  carefully  applied  strips  of  adhesive  plaster.  But 
although  the  patient  appeared  uninjured  by  the  operation  the  fluid  always 
quickly  re-accumulated.  If  the  skull  is  enlarging  rapidly,  I  beheve  the 
strapping  treatment  to  be  decidedly  injurious. 


CHAPTEE  XIII. 

OTITIS   AND   ITS   CONSEQUENCES. 

(Purulent  Meningitis  ;  Thrombosis  of  the  Cerebral  Sinuses  ;  Encephalitis.) 

Otitis  in  the  child  is  a  common  disease,  and  may  lead  to  very  serious  con- 
sequences on  account  of  the  facility  with  which  inflammation  can  extend 
from  the  tympanic  cavity  to  the  interior  of  the  skull.  During  the  first  few 
years  of  life  the  mastoid  process  is  in  a  rudimentary  state.  In  the  young 
child,  therefore,  the  mastoid  cells  are  limited  to  the  horizontal  portion 
which  lies  behind  the  tympanic  cavity,  and  above  and  slightly  posterior  to 
the  auditory  meatus.  It  is  only  at  a  later  period  that  they  extend  down- 
wards and  backwards  to  form  the  hollow  of  the  mastoid  process.  These 
cells  communicate  with  the  tympanum,  and  share  in  any  catarrhal  process 
of  which  that  cavity  may  be  the  seat.  The  tympanum  itself  is  separated 
from  the  interior  of  the  skuU  by  a  thin  layer  of  bone,  which  is  often  a  mere 
translucent  shell.  This,  according  to  Toynbee,  may  even  be  deficient  in 
places,  so  that  the  mucous  lining  of  the  tympanum  is  sometimes  here  and 
there  in  actual  contact  with  the  dura  mater  covering  the  temporal  bone. 
It  is  then  easy  to  understand  how,  without  any  disorganisation  of  the  bony 
layer  itself,  inflammation  may  extend  from  the  tympanic  ca\dty  to  the  in- 
terior of  the  cranium,  and  give  rise  to  serious  disease  of  the  brain  and  its 
membranes. 

The  inflammation  may  spread  from  the  ear  to  the  skull-cavity  through 
either  the  roof  of  the  tympanum  or  that  of  the  mastoid  cells.  It  may  also 
pass  through  the  upper  wall  of  the  external  auditory  canal,  or  be  conveyed 
inwards  by  means  of  the  internal  auditory  meatus,  which  is  lined  by  a 
prolongation  of  the  brain  membranes.  The  petrous  bone  may  or  may  not 
participate  in  the  disease.  Sometimes  it  becomes  carious.  In  other  cases 
serious  disease  of  the  brain  and  its  membranes  may  be  set  up,  although 
the  bony  layer  separating  the  ear  cavities  from  the  interior  of  the  cranium 
seems  in  no  way  affected  by  the  inflammation  around  it. 

Causation. — In  childhood  there  appears  to  be  a  special  tendency  to 
catarrh  of  the  mucous  membrane  lining  the  middle  ear.  Von  Tridtsch 
has  commented  upon  the  frequency  with  which  in  young  persons  this  con- 
dition is  discovered  after  death,  without  any  symptom  of  the  derangement 
having  been  observed  during  the  life  of  the  patient.  The  tendency  is 
heightened  by  the  scrofulous  diathesis,  and  in  the  subjects  of  this  consti- 
tutional state  the  catarrh  has  a  special  proneness  to  become  a  serious  sup- 
puration. Diseases  which  have  an  influence  in  provoking  the  manifesta- 
tions of  the  scrofulous  cachexia  are  very  apt  to  be  followed  by  suppurative 
otitis,  as  scarlatina,  measles,  and  small-pox.  Besides  these  causes,  cold  or 
slight  injuries  to  the  ear  may  set  up  the  same  condition,  and  sometimes 
the  tympanum  becomes  affected  as  a  consequence  of  similar  disease  in 
parts  around.     Thus  inflammation  may  spread  to  the  middle  ear  from 


OTITIS — CAUSATION— MORBID   ANATOMY.  347 

the  external  auditory  meatus  or  from  the  pharynx.  Dr.  Knapp,  of  New 
York,  states  that  in  the  majority  of  cases  the  occurrence  of  suppurative 
catarrh  of  the  middle  ear  is  due  to  cold,  which  affects  first  the  naso-pha- 
ryngeal  cavity,  and  then  spreads  up  the  Eustachian  tube.  In  8.78  per 
cent,  of  his  cases  he  attributes  the  immediate  cause  of  the  otitis  to  sea 
bathing  ;  in  7.74  per  cent,  to  scai-latina.  The  extension  of  the  inflamma- 
tion further  inwards  to  the  skull-cavity  may  be  determined  by  any  agency 
capable  of  setting  up  acute  inflammation  in  the  ear.  Cold  is  a  frequent 
cause  of  this  disaster,  and  blows  upon  the  head  may  produce  the  same 
result.     It  is  an  occasional  complication  of  dentition  (see  page  560). 

Morbid  Avatomy. — When  the  mucous  membrane  lining  the  tympanum 
becomes  acutely  inflamed,  it  is  of  a  deep  red  colour,  and  its  vessels  are  fuU 
and  distended.  In  the  chronic  stage  the  mucous  membrane  becomes 
thickened  and  pours  out  a  copious  purulent  secretion  which  usually  per- 
forates the  tymj)anic  membrane  and  issues  from  the  external  meatus  as  a 
yellowish-white  discharge.  A  chronic  otitis  may  continue  for  months,  or 
even  years,  without  producing  much  inconvenience.  But  sometimes  the 
inflammation  extends  to  the  bony  wall,  which  becomes  carious  and  soft- 
ened ;  or  the  inflammation  suddenly  assumes  an  acute  character.  In  either 
case  violent  symptoms  may  be  all  at  once  noticed  from  implication  of  the 
brain  and  its  membranes.  The  consequences  of  spreading  of  the  inflam- 
mation to  the  skull  cavity  are  the  occurrence  of  purulent  meningitis,  and 
of  encephalitis  with  abscess  of  the  brain. 

In  purulent  meningitis  there  may  be  inflammation  and  thickening  of 
the  dura  mater  (pachymeningitis),  and  this  membrane  may  be  separated 
from  the  petrous  bone.  Often  suppuration  takes  place  between  it  and  the 
bone  ;  the  membrane  is  perforated,  and  pus  is  effused  into  the  cavity  of 
the  arachnoid.  If  disease  of  the  petrous  bone  is  one  of  the  consequences 
of  the  otitis,  thrombosis  of  the  cerebral  sinuses  may  occur,  and  pyaemia 
may  be  produced.  In  all  cases  where  the  dura  mater  is  inflamed,  phlebi- 
tis and  thrombosis  of  the  cranial  sinuses  are  frequent  consequences.  The 
coagulation  of  the  blood  and  arrest  of  the  circulation  in  the  venous  chan- 
nels is  due  to  narrowing  of  the  calibre  of  the  sinus  either  b}^  pressure 
upon  it  of  inflammatory  products  or  by  thickening  of  its  walls  owing  to 
inflammatory  infiltrations  and  abscesses.  As  a  rule  the  lining  membrane 
of  the  sinus  is  smooth,  but  it  sometimes  becomes  roughened  and  dull- 
looking.  The  clot  which  forms  the  thrombus  is  fibrinous,  and  contains  but 
few  red  blood  corpuscles.  It  is  therefore  whitish-yellow  in  colour,  or  slightly 
gelatinous-looking,  from  the  number  of  white  corpuscles.  It  may  lie  free 
in  the  sinus  or  form  loose  adhesions  to  the  walls.  These  decolourised 
clots  are  sometimes  very  extensive,  and  may  reach  from  the  lateral  sinus 
downwards  to  the  vena  cava.  If  the  child  live  long  enough,  the  thrombus 
may  soften  in  the  centre,  and  the  disintegrated  fibrine  may  present  a  pus- 
like appearance  to  the  eye. 

The  pia  mater  is  almost  always  affected.  Its  vessels  become  dilated 
and  filled  with  blood  ;  small  patches  of  ecchymosis  are  scattered  about ; 
and  a  yellowish  or  greenish  exudation  is  poured  into  the  subarachnoid  tis- 
sue. This  exudation  may  be  solid  like  an  ordinary  false  membrane,  but 
is  often  distinctly  purulent.  It  varies  greatly  in  amount.  The  cortex  of 
the  brain,  as  might  be  expected  from  the  intimate  connection  which  exists 
between  its  vessels  and  those  of  the  investing  pia  mater,  usually  shares  in 
the  inflammatory  condition,  and  becomes  injected  and  softened. 

Encephalitis  usually  occurs  in  patches.  The  vessels  are  dilated  and 
congested  ;  there  is  effusion  into  the  tissue  around  them  which  becomes 


348  DISEASE   IlSr   CHILDREJf. 

swollen,  red,  and  soft  (acute  red  softening),  and  can  be  washed  away  by  a 
stream  of  water.  SioiTOunding  the  inflamed  patch  the  cerebral  tissue  is 
congested  and  oedematous,  and  of  a  yellowish  coloiu\  As  the  process 
goes  on  the  coloiu'  of  the  diseased  spot  changes  from  red  to  greenish  ;  its 
substance  gets  softer  and  softer,  and  the  central  part  breaks  down  into  a 
yellow  or  green  purulent  matter.  The  wall  of  the  abscess  thus  formed 
consists  of  brain-substance  more  or  less  softened.  The  seat  of  the  abscess 
in  cases  of  otitis  is  in  the  adjacent  part  of  the  middle  or  posterior  lobe  of 
the  cerebrum,  or  in  the  cerebellum.  As  a  consequence  of  the  abscess  and 
inflammation  of  the  brain-substance  at  the  spot,  there  is  enlargement  of 
the  affected  part  of  the  brain,  its  convolutions  are  flattened,  and  its  sulci 
partly  obhterated. 

To  produce  these  secondary  results  in  the  skull  canity  it  is  not  neces- 
sary that  caries  of  the  petrous  bone  should  occui\  In  many  cases  the  bone 
itself  is  found  intact,  the  dui'a  mater  even  may  have  the  appearance  of 
health,  and  a  layer  of  healthy-looking  cerebral  substance  may  separate  the 
abscess  from  the  sui'faee  of  the  brain. 

Symjitoms.— Acute  otitis  may  be  present  without  any  symptoms  indi- 
cating the  existence  of  the  inflammation.  Usually,  however,  as  the  puru- 
lent secretion  accumulates  in  the  cavity  of  the  tympanum,  especially  if  the 
tympanic  membrane  shares  in  the  inflammation,  there  is  severe  pain  in  the 
ear  and  side  of  the  head,  and  pressui-e  on  or  around  the  ear  increases  the 
suffering.  In  babies  earache  is  a  common  affliction,  and  may  even  be  a 
cause  of  convulsions.  The  child  cries  incessantly  with  a  peculiar  shrill 
scream,  and  refuses  to  be  comforted.  He  burrows  his  head  in  his  pillow, 
or  rests  it  against  his  mother's  shoulder,  often  lifts  his  hand  to  his  head, 
and  refuses  the  bottle  or  the  breast.  If  the  pain  cease  or  subside  for  a 
time,  he  falls  asleep,  but  usually  wakes  up  again  after  a  short  interval 
screaming  loudty,  and  continues  to  cry  again  incessantly  as  before.  After 
some  hours  of  this  agony  the  tympanic  membrane  gives  way,  a  discharge 
of  pus  issues  from  the  meatus,  and  the  cry  at  once  ceases.  Examination 
of  the  ear  in  these  cases  seldom  affords  much  information,  although  the 
passage  sometimes  looks  red  and  inflamed. 

When  a  chronic  otitis  exists,  there  is  a  more  or  less  copious  purulent 
discharge  from  the  ear,  the  tympanic  membrane  is  destroyed,  and  the 
sense  of  hearing  is  blunted.  So  long  as  no  more  pus  is  formed  than  can 
pass  readily  away,  no  other  ill  effects  are  observed,  and  the  absence  of  the 
tympanic  membrane  usually  allows  of  free  escajDe  of  the  matter  exuded. 
Sometimes,  however,  an  accumulation  of  pus  takes  j^lace  in  the  mastoid 
cells,  and  ill  consequences  follow.  The  chief  danger  in  these  cases  is  the 
occurrence  of  a  fresh  acute  attack.  The  otorrhoea  then  ceases  at  once, 
there  is  an  intense  jjain  in  the  ear  and  side  of  the  head,  and  often  menin- 
gitis with  all  its  serious  consequences  ensues.  It  must  be  remembered, 
however,  that  as  otitis  ma}'  exist  withoiit  giving  rise  to  symptoms,  menin- 
gitis occui'ring  as  a  result  of  inflammation  of  the  t^'mj^anum  is  not  always 
preceded  by  otorrhoea.  Sometimes  the  symptoms  of  meningitis  precede 
the  otorrhoea,  and  sometimes  the  otitis  is  latent  throughout. 

In  an  ordinary  case  of  extension  of  the  inflammation  to  the  meninges 
the  sequence  of  symptoms  is  as  follows  :  A  little  child  of  a  few  years  old 
has  a  discharge  of  purulent  matter  from  the  ear.  This  may  have  followed 
an  attack  of  severe  earache,  or  may  have  begun  without  pain  and  continued 
without  discomfort,  although  the  hearing  on  that  side  has  been  noticed  to 
be  dull.  The  otorrhoea  continues  for  several  months.  Occasionally  the 
child  is  feverish  and  complains  of  acute  pain  in  the  affected  ear  and  side 


OTITIS — PURULENT   MENINGITIS.  349 

of  the  head.  At  the  same  time  the  discharge  from  the  meatus  ceases  to 
flow.  After  some  hours,  however,  the  pain  subsides  and  the  running  re- 
appears. At  length  the  patient  is  seized  with  high  fever,  and  has  an  attack 
of  violent  convulsions.  After  several  repetitions  of  the  fits,  in  the  intervals 
of  which  he  seems  drowsy  and  stujDid,  he  sinks  into  a  state  of  coma  and 
dies  within  the  week.  This  is  called  the  convulsive  form — long  standing 
otorrhcea ;  then,  suddenly,  fever,  convulsions,  coma,  death.  It  is  the 
shape  the  disease  takes  in  babies  and  children  under  two  years  of  age. 

The  fever  is  high.  The  temperature  rises  to  between  104°  and  105°, 
and  rmdergoes  at  first  httle  remission  in  the  mornings.  The  pulse  almost 
always  intermits  more  or  less  completely,  and  very  often  falls  in  frequency, 
sinking  to  75  or  80.  This,  however,  is  a  very  variable  symptom,  and 
sometimes  the  pulse  remains  quick  throughout.  Pain  in  the  affected  side 
of  the  head  is  seldom  absent.  The  youngest  children,  in  the  intervals  of 
convulsions,  may  be  noticed  to  moan  and  put  their  hands  to  their  heads. 
Respirations  are  quickened  and  may  be  perfectly  regular,  although  some- 
times we  notice  sighing  respirations,  and  the  breathing  towards  the  end 
may  assume  the  Cheyne-Stokes  type.  The  pupils  are  generally  contracted 
at  first,  and  become  dilated  later.  They  are  often  unequal  in  size.  There 
may  be  squinting  of  one  or  both  eyes,  and  sometimes  we  note  a  paralysis 
of  the  face  on  the  affected  side. 

The  convulsions  are  violent,  and,  for  the  most  part,  bilateral.  In  the 
intervals  consciousness  is  not  completely  restored,  the  child  is  heavy  and 
stupefied,  taking  little  notice  of  persons  and  things  around,  although  his 
attention  can  be  usually  attracted  by  calling  him  loudly  by  name.  He  is 
very  restless,  and  often  keeps  one  or  more  of  his  Hmbs  in  constant  move- 
ment. Rigidity  of  the  joints  may  be  present,  and  if  there  is  any  accom- 
panying spinal  meningitis,  the  head  is  firmly  retracted  on  the  shoulders 
with  rigidity  of  the  muscles  of  the  nucha.  The  abdomen  is  seldom 
markedly  retracted  as  in  tubercular  meningitis,  and  the  characteristic 
doughy  feel  of  the  abdominal  wall  is  also  usually  absent.  The  child  re- 
fuses his  bottle,  and  often  can  scarcely  be  made  to  swallow  hquid  from  a 
spoon.  The  disease  runs  its  course  rapidly.  After  a  day  or  two  the  con- 
vulsions become  less  frequent.  The  child  lies  plunged  in  a  deep  stupor, 
and  after  remaining  comatose  for  a  variable  time,  dies  without  any  retui'n 
of  consciousness.     Sometimes  convulsions  immediately  precede  death. 

In  certain  cases  the  disease  may  run  an  even  shorter  course,  and  death 
take  place  with  starthng  rapidity. 

A  little  boy,  aged  twelve  months,  strong4ooking  and  well  nourished, 
was  seized  with  vomiting  at  1  a.m.  on  February  16th,  and  continued  to 
vomit  at  intervals  for  twelve  hours.  He  then  had  several  fits,  and  at  3  p.m. 
was  brought  to  the  East  London  Children's  Hospital.  He  was  seen  by  IVIr. 
Scott  Battams,  the  house  surgeon,  who  noted  that  all  the  limbs  were  con- 
vulsed and  the  pupils  were  dilated.  When  the  fits  ceased  the  child  still 
continued  insensible  ;  there  was  nystagmus  ;  the  pupils  were  equal  and  di- 
lated, and  acted  well  vdth  Ught ;  the  conjunctivae  were  insensitive  ;  tliere 
was  no  squint ;  the  cerebral  flush  was  fairly  marked  ;  the  limbs  were  flaccid. 

At  8  P.M.  the  child  was  still  insensible.  He  had  had  no  more  fits  ; 
pulse,  150,  with  occasional  intermissions  ;  respirations,  40  ;  temperature, 
103°  ;  pupils  equal,  and  still  acted  with  light. 

All  through  the  night  the  child  remained  insensible.  There  was  no 
vomiting,  and  the  convulsions  were  not  repeated.  No  twitching  was 
noticed,  and  the  head  was  not  retracted.  He  died  at  8  a.m.  Before  death 
the  temperature  was  104°. 


350  DISEASE  liS'   CHILDEE]S^. 

On  examination  of  the  brain,  the  whole  convexity  was  found  coated 
with  yellow  Ivmph  which  had  extended  to  the  under  surface  of  the  fi'ontal 
lobes,  and  had  glued  the  anterior  and  middle  lobes  to  one  another.  There 
was  no  flattening  of  the  convolutions ;  no  excess  of  fluid  in  the  ventricles ; 
no  exudation  in  the  optic  space  ;  and  no  inflammation  of  the  membranes 
at  the  base  of  the  brain.  No  gray  granulations  could  be  seen  ;  the  brain 
was  fii'm,  and  seemed  perfectly  healthy  ;  the  cerebral  sinuses  contained 
semifluid  dark  blood. 

In  this  case  there  was  slight  discharge  from  the  ears,  but  without  of- 
fensive smell.  It  is  doubtful  if  this  had  any  part  in  producing  the  menin- 
gitis, for  the  dura  mater  coveiing  the  petrous  bones  had  a  healthy  appea-r- 
ance.  Nothing  in  the  historj'  of  the  child  could  be  discovered  to  account 
for  the  illness,  for  although  he  had  had  a  cough  for  a  fortnight,  and  had 
whooped  during  the  last  two  days,  this  could  not  be  looked  upon  as 
a  determining  cause  of  the  inflammation.  It  may  be  remarked  that 
the  symptoms  above  described  resemble  exactly  those  often  present  in 
cases  of  meningeal  haemorrhage  in  the  young  child,  with  the  excep- 
tion that  in  this  case  the  temj^erature  was  elevated.  A  raised  tempera- 
ture, present  in  meningitis  and  absent  in  haemorrhage,  aj)pears  to  be 
the  single  important  symptom  by  which  the  two  diseases  may  be  dis- 
tinguished. 

Above  the  age  of  two  years  it  is  usual  for  the  meningitis  to  assume  a 
different  shape.  Convulsions  are  a  less  prominent  symptom ;  instead  we 
find  a  more  or  less  violent  delirium.  Hence  Piilhet — to  whose  labours  all 
descriptions  of  meningitis  in  the  child  are  so  much  indebted — has  called  it 
the  '"'johi-enitic"  form.  It  is  of  longer  dui'ation  than  the  con^-ulsive  variety, 
and  resembles  more  meningitis  as  that  disease  occui-s  in  the  adult.  The 
child  complains  of  severe  headache,  is  agitated  and  restless,  and  very 
rapidly  becomes  delirious.  The  dehrium  is  noisy.  The  child  raves  about 
the  pain  in  his  head.  His  eyes  are  red  and  wild-looking,  his  pupils  con- 
tracted and  often  unequal  in  size.  The  pulse  is  quick  and  iiTeg-ular,  and 
may  be  completely  intermittent.  His  temperatiu'e  is  high,  marking  104° 
or  105^,  as  in  the  preceding  variety  ;  and  his  breathing  is  rapid,  although 
usually  regular.  After  some  days  the  delirium  becomes  less  violent.  The 
child  has  intervals  of  cjuiet  in  which  he  appears  to  be  Tinconscious.  He 
lies  with  his  eyehds  half  open  and  his  eyes  tiu'ned  upwards,  moaning  oc- 
casionaUy  ;  the  muscles  of  his  face  twitch  ;  there  is  trismus  or  gi'inding  of 
teeth  ;  and  his  head  is  often  retracted  upon  his  shoulders.  As  the  disease 
progresses  the  coma  becomes  more  constant,  but  at  first  a  touch  may  ex- 
cite violent  dehrious  straggles,  for  there  seems  to  be  general  hypersesthe- 
sia  making  the  slightest  pressure  paijiful.  The  pupils  dilate,  and  are  in- 
sensible to  light  ;  there  is  often  oscillation  of  the  globe  of  the  eye  and 
squinting.  The  pulse  becomes  very  fi'equent,  and  the  respii'ations  are  of 
the  Cheyne-Stokes  type.  There  may  be  rigidity  of  the  joints.  The  coma 
continues  profound,  and  the  patient  graduaUy  sinks  and  dies.  Usually 
there  is  profuse  sweating  before  death,  although  the  temperature  continues 
high ;  and  the  disease  may  terminate  in  a  fit  of  convulsions. 

Sometimes  the  temperature  falls  considerably  before  death.  At  other 
times  it  rises  rapidly  to  108°,  or  even  higher.  The  duration  of  the  phreni- 
tic  form  of  the  disease  varies  ;  its  course  may  be  rapid  like  that  of  the  con- 
viilsive  varietj^,  but  sometimes  it  is  prolonged  to  thi-ee,  four,  or  more  weeks. 
In  these  slower  cases  the  illness  often  assumes  a  subacute  t^'pe,  with  only 
slight  elevations  of  temperature  ;  but  at  any  time  the  heat  of  the  body  may 
undergo  a  sudden  and  apparently  causeless  increase. 


OTITIS — THEOMBOSIS — ENCEPHALITIS.  351 

In  many  cases  inflammation  of  the  dura  mater  is  accompanied  by 
thrombosis  of  the  cerebral  sinuses.  The  symptoms,  however,  of  this  con- 
dition are  masked  by  those  of  the  accompanying  meningitis  ;  and  its  ex- 
istence, therefore,  can  seldom  be  more  than  suspected.  According  to 
Gerhardt,  we  may  sometimes  detect  on  the  affected  side  comparative 
emptiness  of  the  jugular  vein,  which  is  no  longer  filled  with  blood  from 
the  obstructed  sinus  ;  but  this  is  a  symptom  the  existence  of  which  it 
must  be  difficult  to  ascertain.  In  ordinary  cases  the  occurrence  of  shiver- 
ing, or  great  variations  in  the  temperature,  with  signs  of  metastatic 
deposits  in  the  lungs  (sudden  dyspnoea,  cough,  and  perhaps  scattered  zones 
of  crepitation  about  the  chest  or  back)  would  point  to  the  probable  occur- 
rence of  cerebral  phlebitis. 

When  meningitis  occurs  as  a  consequence  of  other  causes  than  otitis, 
the  symptoms  are  as  described,  with  the  addition,  in  most  cases,  of  a  pre- 
liminary stage  in  which  the  child  complains,  if  old  enough,  of  headache, 
gradually  increasing  in  intensit}^  He  is  feverish,  vomits,  is  very  restless, 
and  his  ideas  are  confused.  The  course  of  the  disease  is  therefore  rather 
longer  than  in  the  form  described  above. 

Inflammation  of  the  brain  (encephalitis)  is  more  frequently  than  the 
jjreceding  a  consequence  of  otitis.  Indeed,  it  has  been  estimated  that  fully 
haK  of  the  cases  of  abscess  of  the  brain  are  due  to  inflammation  originating 
in  the  middle  or  internal  ear.  The  inflammation  is  limited  to  certain 
spots,  being  usually  confined  to  the  cerebrum  in  the  immediate  neigh- 
bourhood of  the  petrous  bone.  Sometimes,  however,  it  is  found  in  children, 
as  it  is  commonly  in  the  adult,  in  the  cerebellum. 

The  symptoms  are  often  obscured  by  meningitis,  which  may  exist  at 
the  same  time  ;  and  there  may  be  thrombosis  of  the  cranial  sinuses. 

The  disease  begins  with  pain  in  the  head,  which  is  indicated  in  the 
young  child  by  repeated  screaming  and  frequent  movement  of  the  hand  to 
the  head.  The  child  seems  drowsy,  and  behaves  as  if  only  half  awake.  He 
takes  food  unwillingly  or  refuses  it  altogether.  The  bowels  are  generally 
confined,  and  there  is  usually  vomiting.  The  temperatui'e  seldom  rises 
above  102°.  The  pulse  is  generally  slow  (70  to  80),  and  the  pupils  are 
contracted.  The  di'owsiness  soon  deepens  into  stupor,  and  there  is  rigid- 
ity of  the  joints,  usually  limited  to  one  side,  with  perhaps  paresis  or 
paralysis  of  the  Hmbs.  Much  depends  upon  the  seat  of  the  abscess,  and 
whether  it  affects  the  centres  of  special  sense  or  interferes  with  the  con- 
duction of  motor  influences.  Thus  there  may  be  incomplete  hemij^legia 
from  compression  of  the  fibres  of  the  internal  capsule  ;  paralysis  of  the 
third  nerve  from  pressiu'e  on  the  cerebral  peduncle  ;  or  paralysis  of  the 
facial  nerve.  The  loss  of  power  is  almost  invariably  Hmited  to  one  side  of 
the  body.  Convulsions  may  occur  ;  there  are  frequent  twitchings  of  the 
facial  muscles,  and  the  child  grinds  his  teeth  and  makes  movements  with 
his  mouth  as  if  chewing.  The  stupor  is  not  constant.  At  first  the  child 
can  be  roused  by  being  spoken  to  loudly  ;  and  occasionally  the  mind  be- 
comes clearer  after  a  time.  The  child  will  often  begin  again  to  answer 
questions,  and  may  even  recognise  his  friends.  The  respu-ations  are  quick- 
ened and  very  irregular ;  the  pulse,  after  the  first  few  days,  increases  in 
rapidity,  and  often  becomes  intermittent.  In  acute  cases  the  stupor  soon 
becomes  more  profound,  and  deepens  into  a  coma  in  which  the  child  dies. 
Convulsions,  if  previously  present,  may  cease  when  the  patient  becomes 
comatose,  or  may  return  before  death.  The  temperature  remains  moder- 
ately elevated  throughout,  or  falls  notably  before  the  fatal  termination,  or 
rises  to  a  his'h  level  during  the  last  few  hours  of  life. 


DISEASE  IIT   CHILDEEN. 

A  rickety  little  boy,  aged  two  years,  was  admitted  into  the  East  Lon- 
don Children's  Hospital  with  the  symptoms  of  severe  pulmonary  catarrh. 
For  some  months  the  child  had  been  subject  to  otorrhoea,  but  there  was 
no  history  of  earache.  He  went  on  well  at  first ;  the  cough  improved  and 
his  chest  seemed  greatly  relieved,  when,  on  December  7th,  his  temperature 
rose  to  102°,  and  there  was  a  copious  discharge  of  pus  from  the  left  ear. 
The  discharge  continued  through  the  week,  but  the  child  seemed  to  suffer 
little  inconvenience  fi'om  the  state  of  his  ear.  He  was  lively,  took  his 
food  with  appetite,  and  his  temperature,  which  for  a  few  days  had  been 
high,  again  sank  to  99"^. 

On  December  13th  a  change  was  noticed.  The  child  screamed  fre- 
quently and  seemed  indifferent  to  his  food.  His  temperature  that  evening 
was  only  99°,  On  the  morning  of  the  14th  the  temperature  was  still  99°, 
but  the  pulse,  which  had  been  always  considerably  over  100,  was  found  to 
have  fallen  to  80.  The  child  was  drowsy  and  could  not  be  thoroughly 
roused.  He  lay  on  his  right  side  with  a  puffy-looking  flushed  face,  grind- 
ing his  teeth  and  making  other  movements  with  his  jaws.  The  pupils 
were  equal,  slightly  contracted,  and  sluggish  ;  occasionally  there  was  a 
slight  squint.  Some  rigidity  was  noticed  of  the  right  knee  and  elbow 
joints.  The  child  took  no  notice  of  questions  and  refused  food.  At  6  p.m. 
the  temperatiu-e  was  100°  ;  pulse,  96  ;  respirations,  34 ;  and  in  the  evening 
the  stupor  deepened  into  coma. 

For  the  next  forty-eight  hours  the  child's  state  continued  much  the 
same.  He  was  completely  insensible,  and  squinted  outwards  with  the 
right  eye.  During  this  time  his  temperature  was  101°-101,4°  ;  pulse,  120- 
130  ;  respiration,  21-48,  and  very  irregular.  The  abdomen  was  slightly 
retracted  ;  the  bowels  were  confined,  and  he  vomited  once. 

On  December  16tli  the  bowels  had  been  moved  by  aperients,  and  there 
was  some  approach  to  consciousness.  The  child  resisted  the  feeding  cup, 
and  in  the  evening  seemed  to  recognise  the  nurse.  He  was  heard  to  say 
"  no  "  repeatedly  when  offered  drink.  He  could  move  both  his  legs.  The 
temperature  was  100°-101°. 

On  December  17th  the  stupor  was  even  less,  although  the  patient  re- 
mained very  drowsy  ;  he  tvirned  his  head  when  called  loudly  by  name,  and 
answered  when  asked  to  drink.  There  was  no  flushing  of  the  face,  nor  any 
redness  when  pressure  was  made  on  the  skin.  Temperature,  100°-101.6°  ; 
pulse,  156  ;  respirations,  38.  On  the  18th  the  child  had  two  fits.  These 
were  followed  by  no  rigidity  of  the  joints ;  but  the  patient  lay  in  a  semi-coma- 
tose condition,  although  it  was  stiU  possible  to  rouse  him  by  loud  calling. 
From  that  time  he  gradually  sank,  and  died  on  the  afternoon  of  the  follow- 
ing day.  The  temperature  shortly  before  death  was  101°.  On  examina- 
tion of  the  body,  the  petrous  part  of  the  temporal  bone  was  found  de- 
nuded of  dura  mater  at  one  spot,  and  the  membrane  around  was  much  in- 
flamed. An  abscess  was  discovered  in  the  adjacent  cerebellum  fiUed  with 
offensive  pus,  and  there  was  excess  of  fluid  in  the  lateral  ventricles. 

The  course  of  encephalitis  is  usually  rapid.  It  may  last  only  five  or  six 
days,  or  may  be  prolonged  to  two  or  three  weeks.  Sometimes  after  a  time 
the  acute  symptoms  disappear,  consciousness  is  recovered,  and  the  child's 
health  may  appear  to  be  restored.  It  is  even  said  that  such  children  may 
grow  up  to  adult  age,  the  abscess  having  become  encysted  and  ceasing  to 
be  a  sovirce  of  irritation. 

Diagnosis. — Otitis  should  be  suspected  in  all  cases  where  a  young  child 
cries  incessantly  without  any  symptoms  being  detected — such  as  drawing 
up  of  the  legs,  tension  of  the  abdominal  wall,  unhealthy  evacuations,  etc. — 


♦  OTITIS — DIAGNOSIS.  •  353 

to  draw  attention  to  the  belly.  Abdominal  pain  is  intermittent,  and  tlie 
cries  cease  wlien  the  uneasiness  subsides.  Earache  is  constant,  and  until 
relief  is  obtained  by  the  discharge  of  pus  from  the  meatus  the  child  cries 
with  a  persistence  which  is  very  characteristic. 

When  pui"ulent  meningitis  occurs,  the  onset  of  violent  convulsions,  with 
high  fever,  following  upon  sudden  cessation  of  discharge  from  the  ear,  are 
very  suspicious  ;  and  when  we  remark  that  in  the  intervals  of  the  fits  the 
child  remains  drowsy  and  stupid,  refuses  food,  and  takes  no  notice  of  ac- 
customed faces  ;  that  he  is  restless,  contracts  his  brows,  and  constantly 
moves  his  hand  to  his  head,  we  can  speak  with  some  confidence  as  to  the 
nature  of  the  case.  In  reflex  convulsions  the  mind  is  clear  between  the 
attacks.  Drowsiness  or  stupor  with  i-ecurring  convulsive  movements  is 
very  characteristic  of  a  cerebral  origin.  An  alteration  in  the  pulse  adds 
a  new  and  important  feature  to  the  case.  A  pulse  of  80  in  a  young  child 
is  a  slow  pulse.  If  the  child  be  feverish,  the  contrast  between  the  bodily 
heat  and  the  comparative  infrequency  of  the  arterial  pulsations  is  still  more 
striking.  Therefore  if  to  the  preceding  symptoms  we  add  a  slow  and  per- 
haps intermitting  pulse,  our  suspicions  are  sufficiently  confirmed. 

Fevers  or  inflammatory  diseases  in  the  young  child  may  begin  with  the 
combination  of  pyrexia  and  convulsions.  In  the  case  of  the  exanthemata 
we  should  find  some  of  the  early  symptoms  of  the  eruptive  fever  ;  and 
the  convulsive  movements  themselves  are  few  and  not  violent.  There 
is  little  restlessness,  and  between  the  attacks  the  child  takes  notice  and 
recognises  his  friends.  In  the  case  of  malignant  scarlatina,  beginning  with 
convulsions  and  dehriitm,  there  is  little  headache,  and  the  eruption  appears 
within  twenty-four  hours  of  the  first  symptoms  of  the  fever. 

Pneumonia  in  the  child  not  unfrequently  begins  with  convulsions,  and 
there  is  high  pyrexia  ;  but  the  absence  of  stupor  and  of  headache,  the  ac- 
tion of  the  nares,  the  greater  rapidity  of  the  breathing,  and  the  perverted 
pulse-respiration  ratio  would  serve  to  exclude  meningitis  although  a  physi- 
cal examination  of  the  chest  might  reveal  no  signs  of  disease.  In  the  so- 
called  "  cerebral  pneumonia,"  where  there  is  delirium  and  headache,  with 
stupor  and  high  fever,  the  nature  of  the  disease  may  be  often  detected 
early  by  an  examination  of  the  chest.  Sometimes,  however,  physical  signs 
are  slow  to  appear,  and  in  such  a  case  we  must  wait  before  pronouncing 
an  opinion.  Usually  the  head  symptoms  of  cerebral  pneumonia  are  not 
violent,  but  assume  more  the  characters  of  tubercular  meningitis  than  of 
the  simple  form  of  the  disease.  The  distinction  between  these  two  varie- 
ties of  meningitis  will  be  considered  elsewhere  (see  Tubercular  Meningitis). 

From  uraemia  and  the  various  forms  of  cranial  disease  unaccompanied 
by  pyrexia,  the  high  temperature  which  is  one  of  the  characteristic  features 
of  simple  meningitis  will  form  a  sufficient  distinguishing  mark. 

In  the  case  of  encephalitis,  drowsiness  with  convulsions  or  rigidity  of 
joints,  or  both,  followed  by  coma  and  hemiplegia — the  symptoms  occurring- 
in  a  child  the  subject  of  chronic  otorrhoea,  or  following  upon  an  attack  of 
severe  "earache, — sufficiently  reveal  the  nature  of  the  disease.  When  there 
is  no  paralysis  it  is  difficult,  perhaps  impossible,  to  distinguish  inflamma- 
tion of  the  substance  of  the  brain  from  inflammation  merely  of  its  mem- 
branes, and  a  certain  amount  of  meningitis  usually  accompanies  the  en- 
cephalitis. 

Thrombosis  of  the  cerebral  sinuses  can  seldom  be  more  than  suspected.. 

If  the  dura  mater  be  inflamed,  it  is  reasonable  to  suppose  that  the  sinuses. 

at  the  seat  of  disease  are  also  implicated.     If  in  a  case  where  the  cerebral 

symptoms  have  evidently  followed  upon  a  long  standing  otorrhoea  we  cam 

23 


354     .  DISEASE  IN   CHILDEEE".  9 

detect  deficient  filling  of  the  jugtdar  vein  on  the  affected  side,  or  can  dis- 
cern signs  of  pyaemia — rigors,  or  rapid  variations  of  tem23erat-iire,  vdth 
evidence  of  metastatic  deposits  in  the  lungs  or  other  organs — we  may  con- 
clude that  thrombosis  in  the  sinuses  has  probably  occui-red. 

Prognosis. — Otitis  can  usually  be  cured  by  suitable  treatment,  and  if, 
while  the  discharge  continues,  proper  measures  be  taken  to  jDrevent  the 
collection  of  XDurulent  matter  in  the  tympanic  cavity  or  mastoid  cells,  there 
is  no  reason  to  apjDrehend  any  ill  results  from  the  state  of  the  ear. 

If  extension  of  the  inflammation  take  place  to  the  skull  cavity,  the  vrorst 
consequences  may  be  anticipated.  The  jDatient  does  not,  indeed,  always 
die,  but  the  proportion  of  recoveries  is  very  small.  In  encephalitis  it  is 
common  for  the  stupor  to  clear  away  more  or  less  completely  for  a  time, 
and  therefore  false  hopes  should  not  be  raised  by  the  patient's  apparent 
amendment ;  and  the  friends  should  be  warned  that  such  signs  of  im- 
provement are  seldom  to  be  trusted. 

Treatment. — When  otitis  occurs,  it  is  important  to  remove  pus  early 
from  the  interior  of  the  tympanum.  This  is  done  by  inflating  the  Eusta- 
chian tube  by  means  of  Pohtzer's  bag.  The  operation  is  easily  performed 
upon  children,  as  it  is  not  necessary  that  they  should  swallow.  All  that  is 
required  is  to  send  a  forcible  blast  of  air  through  their  closed  nostrils.  If 
the  purulent  contents  are  not  removed  by  this  means  the  tympanum  must 
be  punctured.  When  a  discharge  appears  from  the  meatus,  the  passage 
should  be  syi-inged  several  times  daily  vdth  warm  water.  If  any  uneasiness 
appears  to  be  felt  in  the  ear,  coimter-irritation  with  tinctm-e  of  iodine  may 
be  employed  behind  the  pinna. 

A  chi-onic  otorrhoea  should  be  stopped  as  quickly  as  possible.  Any 
mild  astringent  injection  may  be  emj^loyed  ;  but  cai'e  should  be  taken 
thoroughly  to  cleanse  out  the  passage  with  warm  water  before  using  the 
astringent  lotion.  In  obstinate  cases  the  use,  several  times  daily,  of  an  ap- 
plication composed  of  sulphate  of  zinc  and  borax,  ten  grains  of  each,  and 
one  drachm  of  glycerine,  to  the  ounce  of  water,  will  often  arrest  the  discharge 
very  quickly.  Glycerine  of  tannin  diluted  in  the  proportion  of  one  di-achm 
to  the  ounce  of  water,  used  frequently,  is  often  of  sexwice.  Sometimes  the 
injection,  once  daily,  of  a  solution  of  nitrate  of  silver  (gT.  x.  to  the  oz.) 
will  hasten  the  cure.  In  cases  of  long-standing  otoiThoea,  when  the  mem- 
brane of  the  tympanum  is  destroyed,  the  child  shordd  wear  small  pledglets 
of  cotton  wool  in  the  ear,  excej)t  in  very  wai'm  weather,  as  a  fi-esh  catarrh 
is  easily  excited  by  cold  and  damp. 

"WTien  meningitis  occui's,  the  room  should  be  kept  in  a  half  hght ;  free 
ventilation  and  perfect  quiet  should  be  insisted  upon  ;  and  the  thermometer 
must  be  watched  that  the  temperatui'e  of  the  room  does  not  rise  above  60°. 
The  feet  must  be  kept  warm  and  the  head  cool.  It  is  advisable  to  remove 
the  hair,  and  keep  the  shaven  scalp  constantly  covered  with  an  ice-bag. 
The  bowels  must  be  opened  freely  by  aperients,  such  as  calomel  and 
jalap.  Opinions  differ  as  to  the  value  of  morjohia  in  these  cases.  Moi-phia, 
even  if  it  j^roduces  no  impression  upon  the  inflammation  itself,  can  scarcely 
be  injurious.  Its  use  has  at  any  rate  this  advantage,  that  when  the  child  is 
kept  under  its  influence  the  more  violent  symptoms  are  moderated,  and 
much  pain  is  saved  to  the  friends  by  the  apparent  rehef  thus  extended  to 
the  patient's  sufferings.  Counter-ii-ritation,  although  often  advocated,  is  of 
Httle  value  ;  and  the  old  jjlan  of  leeching  behind  the  ears  has  never  seemed 
to  me  to  be  followed  by  any  improvement.  Oui-  great  trust  should  be 
placed  in  the  constant  application  of  cold  to  the  head,  in  perfect  quiet,  and 
in  free  purgation.     Encephahtis  is  to  be  treated  on  similar  principles. 


CHAPTER  XIV. 

TUBEECULAR   MENINGITIS. 

A  BASIC  meningitis  induced  by  tuberculosis  of  the  pia  mater  is  undeni- 
ably the  commonest  form  of  intra-cranial  disease  to  be  met  with  in  the 
child.  The  symptoms  to  which  this  variety  of  meningitis  gives  rise  are 
sufficiently  characteristic  to  merit  a  separate  description  ;  for  the  seat  of 
the  inflammation,  the  insidious  beginning  of  the  illness,  and  its  well-de- 
fined course  are  very  different  from  what  we  find  in  simple  inflammation 
of  the  meninges,  and  make  the  affection  for  all  practical  purposes  a  differ- 
ent disease. 

Infants  and  children  of  all  ages  are  subject  to  tubercular  meningitis. 
It  is  little  less  common  in  infants  than  it  is  in  older  children  ;  but  in  the 
former  the  disease  invariably  occurs  in  the  course  of  an  attack  of  general 
tuberculosis.  It  is  then  called  "  secondary,"  for  its  symptoms,  being  pre- 
ceded by  others  arising  from  inflammatory  affections  of  various  organs  also 
dependent  upon  the  diathetic  state,  are  completely  masked  in  their  earlier 
stages,  and  only  reveal  themselves  as  the  more  violent  phenomena  which 
mark  the  closing  period  of  the  illness.  After  the  age  of  infanc}^  the  dis- 
ease usually  assumes  the  primary  form,  for  although  other  organs  may  be 
the  seat  of  tubercle,  the  symptoms  first  noticed  are  those  arising  from  the 
brain,  and  these  retain  their  prominence  throughout  the  course  of  the 
attack. 

Causation. — As  a  form  of  acute  tuberculosis,  tubercular  meningitis  is 
dependent  upon  the  same  predisposing  causes  as  those  which  give  rise  to 
the  diathetic  condition.  It  is  worthy  of  remark  that  in  families  in  which 
the  tubercular  diathesis  exists,  not  only  the  tendency  to  tubercular  forma- 
tion is  handed  down,  but  often,  also,  a  proneness  to  the  particular  shape 
the  disease  is  to  assume.  This  is  especially  the  case  with  regard  to  the 
meningeal  form  of  the  maladj'.  It  is  not  uncommon  to  hear  of  several 
children  of  the  same  family  being  carried  off  by  tubercular  meningitis  ; 
and  in  doubtful  cases  the  fact  that  a  previous  child  has  fallen  a  victim  to 
the  intra-cranial  inflammation  becomes  an  important  aid  in  arriving  at  a 
decision. 

Although  children  who  become  the  subjects  of  this  disease  are  often 
weakly  and  delicate-looking,  with  a  marked  tubercular  family  history,  this 
is  not  always  the  case.  It  is  not  uncommon  to  see  the  disease  break  out 
in  children  who  are  stout  and  vigorous,  and  who'^'certainly  differ  widely 
in  aspect  from  the  delicately  formed  and  frail-looking  type  which  is  con- 
sidered characteristic  of  the  tubercular  diathesis.  It  is  possible  that  infec- 
tion of  the  system  by  softening  cheesy  matter  may  induce  the  disorder  in 
a  child  free  from  any  constitutional  tendency  to  this  form  of  illness  ;  but 
in  most  cases,  however  unlikely  a  subject  the  child  may  appear  to  be,  care- 
ful inquiry  will  discover  evidences  of  "  consumptive  "  tendency  in  collateral 
branches  of  the  family,  if  not  in  the  direct  line  from  which  the  child  has 


356  DISEASE   IN   CHILDEEN. 

descended.  The  disease  is  common  in  all  ranks  of  life  ;  but  as  poverty 
(which  too  often  implies  reckless  indifference  to  insanitary  agencies,  or 
helpless  submission  to  them,  even  more,  perhaps,  than  actual  privation  of 
food)  may  help  to  determine  the  outbreak,  the  affection  is  especially  com- 
mon amongst  the  poor. 

Of  the  exciting  causes,  possibly  any  injury  or  shock  to  the  head,  such 
as  blows  or  exposure,  may  help  to  induce  the  illness.  Over-excitenient  of 
the  mind,  whether  from  study  or  amusement,  may  not  improbably  have 
the  same  effect.  It  has  been  denied  that  pressing  sensitive  children  for- 
wards in  their  learning  can  act  injuriously  in  this  direction.  I  am,  how- 
ever, strongly  of  opinion  that  such  heedless  expedition  is  very  hurtful  to 
the  child,  and  has  often  determined  the  occurrence  of  the  meningeal 
inflammation  in  subjects  predisposed  to  tubercle. 

Ilorhid  Anatomy. — The  starting-point  of  the  disease  is  the  development 
on  the  pia  mater  of  numerous  gray  granulations  as  a  result  of  the  consti- 
tutional state.  These  gray  nodules  are  found  especially  on  that  part  of 
the  membrane  which  covers  the  base  of  the  cerebrum.  On  the  pia  mater 
of  the  cerebellum  and  convexity  of  the  brain  they  are  much  less  numerous, 
and  indeed  appear  often  to  be  quite  absent  from  these  situations.  On 
careful  insj)ection  the  gray  or  yellow  nodules  may  be  noticed  following  the 
course  of  the  vessels,  especially  of  their  smaller  branches.  They  chiefly 
congregate  in  and  about  the  Sylvian  fissure,  and  may  be  often  seen  also  in 
the  chiasma  of  the  oi^tic  nerve.  If  very  numerous,  they  may  be  found 
sprinkled  about  like  a  fine  glistening  dust  in  these  regions  and  along  the 
sides  of  the  hemispheres.  The  larger  granules  may  be  as  big  as  a  pin's 
head  or  even  a  hempseed.  By  the  microscope  the  small  nodular  bodies 
are  observed  to  lie  upon  the  vessels  within  the  perivascular  canals,  and  to 
adhere  closely  to  theii-  coats.  On  the  larger  branches  they  form  projec- 
tions on  one  side  of  the  artery.  On  the  smaUer,  they  may  completely 
embrace  the  vessel.  In  either  case — and  this  is  an  essential  particular — 
they  project  inwards  as  well  as  outwards,  so  as  to  narrow  the  channel  of 
the  tube ;  and  they  may  even  perforate  the  delicate  coats  and  protrude 
into  the  interior  of  the  vessel.  The  granulations  are  formed  by  excessive 
proliferation  of  nuclei  from  the  epithelial  lining  of  the  perivascular  canals  ; 
and  the  obstruction  to  the  vascular  channels  which  results  from  this  ex- 
cessive accumulation  causes  thrombosis  within  the  small  vessels,  great 
impediment  to  the  circulation,  severe  congestion,  and  extensive  collateral 
fluxions. 

As  the  meningeal  tuberculosis  is  usually  merely  a  part  of  a  general  dis- 
tribution of  "tubercle"  over  the  bod}^,  the  gray  granulation  is  found  also 
in  other  organs  and  serous  membranes,  and  has  been  noticed  by  Cohnheim 
on  the  vascular  tunic  of  the  retina. 

The  vessels  of  the  pia  mater  are  engorged,  and  the  membrane  is  cloudy 
and  often  adheres  closely  to  the  surface  of  the  brain,  so  that  when  torn 
away  it  brings  with  it  small  particles  of  the  cerebral  substance.  More  or 
less  coitions  yellowish  or  greenish  jelly-hke  exudation  is  found  in  the 
meshes  of  the  subarachnoid  tissue,  often  running  in  streaks  along  the 
course  of  the  vessels.     It  is  usually  confined  to  the  base  of  the  brain. 

An  almost  invariable  feature  in  these  cases  is  the  ventriciilar  effusion. 
This  is  so  constant  a  phenomenon  that  it  used  to  be  looked  upon  as  con- 
stituting the  essence  of  the  disease  (hence  the  name  of  "  acute  hydroceph- 
alus," by  which  the  affection  was  formerly  distinguished).  The  quantity 
is  often  very  considerable.  It  may  distend  the  ventricles,  flatten  the  con- 
volutions, and  even  cause  rupture  of  the  septum  lucidum.     In  appearance 


TUBEECULAR  MENINGITIS — MOEBID   ANATOMY.  357 

it  is  clear,  or  turbid  with  suspended  flocculent  particles,  or  tinged  with 
blood.  The  cerebral  substance  around  the  ventricles  is  softened.  The 
softening  is  attributed  by  some  writers  to  the  effects  of  mere  imbibition  and 
maceration.  Others  ascribe  it  to  inflammation.  Dr.  Bastian  is  inclined  to 
the  opinion  that  it  is  often  the  result  of  degenerative  changes  set  up  by 
the  anasarcous  condition  of  the  central  brain  tissue ;  and  tkat  both  the 
ventricular  effusion  and  the  softening  result  from  the  pressure  of  the  blood 
in  the  overloaded  veins  and  capillaries,  and  in  some  cases,  perhaps,  from 
actual  thrombosis  in  the  veins  of  Galen. 

Besides  this  softening  of  the  central  parts  of  the  brain,  the  cortical 
substance  is  inflamed  as  well  as  the  pia  mater  which  invests  it,  and  some- 
times spots  of  softening  with  capillary  haemorrhages  have  been  seen  in  the 
substance  of  the  corpora  striata  and  the  optic  thalami.  As  a  rule  the  brain 
substance  is  pale  and  bloodless,  and  the  greater  the  ventricular  effusion  the 
whiter  and  softer  the  cerebral  tissue  becomes. 

The  above  morbid  appearances  are  singularly  constant  in  cases  of 
tubercular  meningitis.  The  granulations,  the  exuded  lymph,  the  vascular 
engorgement,  the  superficial  encephalitis,  the  ventricular  effusion,  and  the 
white  softening  of  the  ventricular  walls  are  almost  invariably  to  be  dis- 
covered when  death  has  occurred  from  this  disease.  In  addition,  signs  of 
more  or  less  general  tuberculosis  are  also  present.  These  in  infants  are 
usually  well  marked,  and  almost  all  the  other  organs  and  serous  membranes 
may  be  sprinkled  over  with  the  gray  granulation.  In  older  children,  how- 
ever, the  meningitis  occurs  before  nutrition  has  been  appreciably  impaired, 
and  is  perhaps  itself  the  earliest  indication  of  the  diathesis.  In  such  cases 
the  other  organs  may  be  healthy,  and  the  granulations  scattered  over  the 
pia  mater  may  be  the  only  morbid  formation  to  be  discovered  in  the  body. 
Usually,  however,  signs  of  the  cachexia  are  perceptible  in  other  organs, 
and  sometimes  the  granulations  are  so  equally  and  generally  distributed 
that  we  cannot  but  wonder  at  the  little  interference  the  constitutional  and 
local  states  had  exercised  upon  the  general  health  of  the  patient. 

Symjptoms. — The  onset  of  the  illness  is  almost  always  preceded  by  a  pro- 
dromal period  of  variable  duration.  This  is  to  be  expected  in  every  malady 
where  disease  of  special  organs  is  dependent  upon  a  general  diathetic  state. 
In  all  forms  of  tubercular  disease  it  is  a  rule  which  is  rarely  infringed  that 
local  symptoms  are  preceded  by  phenomena  indicating  the  general  disorder 
of  nutrition  induced  by  the  constitutional  cachexia. 

The  premonitory  symptoms  vary  in  severity,  partly  according  to  the 
age  of  the  child,  partly  according  to  the  previous  state  of  his  health,  and 
partly  according  to  the  intensity  of  the  diathetic  influence  to  which  he  is 
subject.  In  young  babies,  in  whom  the  disease  invariably  occurs  at  the 
end  of  an  attack  of  general  tuberculosis,  the  head  symptoms  are  preceded 
by  others  indicative  of  the  disease  from  which  he  has  been  suffering.  In 
older  children,  especially  in  those  in  whom  the  diathetic  tendency  is  com- 
paratively feeble,  the  prodromal  period  may  be  short  and  the  symptoms 
trifling.  Therefore  in  diflerent  cases  we  may  find  marked  variety  in  the 
duration  and  severity  of  the  symptoms  which  immediately  precede  the 
outbreak  of  the  disease. 

Two  forms  of  tubercular  meningitis,  a  primary  and  a  secondary  form, 
will  be  described. 

In  primary  tubercular  meningitis  the  prodromal  period  is  often  short, 
and  its  symptoms,  on  account  of  their  indefinite  character,  may  excite  little 
attention.  The  child  is  thought  not  to  look  well,  but  he  makes  no  com- 
plaint for  he  suffers  no  pain.     He  generally  becomes  thinner  and  paler, 


358  DISEASE   IN   CHILDEEN. 

and  liis  appetite  is  capricious.  The  loss  of  flesli  is,  however,  seldom  con- 
siderable, and  may  be  only  recognised  by  the  use  of  the  weighing  scales, 
for  no  diminution  in  bulk  may  be  visible  to  the  eye.  He  is  usually  hstless 
and  nn^Nnlh'ng  to  exert  himself  ;  sits  and  lies  about  instead  of  joining  in 
the  sports  of  his  companions,  and  if  urged  to  take  part  in  their  games,  ob- 
jects that  he  is  tired.  He  is  often  drowsy,  and  may  be  noticed  to  stop  in 
the  middle  of  some  childish  employment  and  fall  asleep  on  the  floor  of  the 
room.  A  change  in  character  is  frequently  noticed  ;  and  this  is  a  symptom 
so  common  that  it  should  be  always  inquired  for.  The  change  is  usually 
indicated  by  an  increase  in  his  emotional  sensibihty.  If  reproved,  he 
shows  exaggerated  distress  ;  his  endearments  exhibit  an  unaccustomed 
warmth  ;  he  readily  takes  offence,  and  cries  without  apparent  reason,  or 
sits  moody  and  silent  in  a  corner  of  the  room.  A  certain  sluggishness  of 
mind  is  also  apparent.  An  ordinarily  bright  child  becomes  stupid  over 
his  lessons  ;  he  seems  drowsy  and  incapable  of  fixing  his  mind  upon  his 
task.  There  may  be  headache,  and  he  may  say  that  the  room  seems  turn- 
ing round.  Sometimes  there  is  confusion  of  sight.  The  bowels  may  be 
irregular  and  costive.  The  temperature  during  this  period  is  often 
slightly  elevated,  and  the  child  looks  flushed  at  night  and  has  hot  dry 
hands.  In  one  case  which  came  under  my  own  notice  the  evening  tem- 
perature for  the  five  nights  immediately  preceding  the  outbreak  was. 
100.4°,  98.4°,  98°,  99.6°,  and  97.6°. 

The  special  symptoms  of  the  disease  are  usually  divided  into  three 
stages  ;  and  when  the  affection  is  a  primary  one  this  arrangement  is  justi- 
fied by  clinical  observation.  There  is  a  stage  of  invasion,  in  which  the  in- 
definite symptoms  of  the  prodromal  period  are  suddenly  broken  in  upon 
by  the  first  indications  of  local  mischief  ;  a  stage  of  irritation,  in  which  there 
is  exalted  nervous  activity  ;  and,  finally,  a  third  stage,  which  is  marked  by 
diminution  of  nervous  power  and  abolition  of  the  functions  of  life. 

The  first  symptoms  of  the  stage  of  invasion  are  in  the  large  majority 
of  cases  vomiting  and  headache,  and  the  bowels  which  were  before  costive 
become  obstinately  constipated.  The  vomiting  is  often  repeated  and 
distressing,  and  occurs  without  any  reference  to  taking  food.  ^  It  is,  in- 
deed, characteristic  of  a  cerebral  origin  that  retching  and  vomiting  occur 
in  the  intervals  of  the  meals — towards  the  end  of  digestion  when  the  stom- 
ach is  nearly  empty.  The  heaving  is  often  excited  by  raising  the  child  up 
into  a  sitting  position.  The  matters  ejected  consist  of  food  and  bilious 
or  watery  fluid.  The  headache  is  generally  severe.  It  is  referred  to  the 
front  or  top  of  the  head,  and  seems  to  occur  in  paroxysms  so  that  the 
patient  screams  out  with  pain.  The  cephalalgia  is  increased  by  movement 
or  by  a  bright  light,  and  is  accompanied  by  dizziness  so  that  the  child 
staggers  in  his  walk.  The  expression  is  distressed,  and  may  be  irritable 
or  spiteful.  The  tongue  may  be  clean,  but  is  often  thickly  furred  ;  the 
thirst  is  often  great,  and  appetite  is  completely  lost.  The  child  takes 
early  to  his  bed,  from  which  he  never  again  rises.  The  abdomen  is  of  nor- 
mal fulness  to  the  eye,  bat  its  parietes  have  a  peculiar,  soft,  doughy  feel, 
which  is  very  characteristic,  and  are  easily  compressible.  Often  there  is 
marked  loss  of  elasticity  of  the  skin.  The  pulse  is  generally  rapid  and 
regular  at  this  time,  but  may  be  slow,  and  sometimes  a  faU  in  the  rapidity 
of  the  pulse  is  the  earliest  symptom  noticed.  Thus,  in  the  child  whose 
case  has  been  referred  to,  a  fall  in  the  pulse  from  100  to  74  occurred  on 
the  evening  preceding  the  actual  outbreak.  The  temperature  is  moder- 
ately elevated  (100°  to  101°).  The  breathing  is  generally  irregular,  and 
may  be  unequal  and  sighing  from  the  first.     This  is  a  symptom  of  great 


TUBEECULAR   MENINGITIS — SYMPTOMS.  359 

importance.  The  cliild  takes  several  quick  breaths  in  rapid  succession. 
Then  the  respiratory  morements  cease,  and  during  some  seconds  the  chest 
is  motionless.  The  patient  then  heaves  a  deep  sigh  and  pauses  again,  or 
his  breathing  returns  for  a  few  minutes  to  the  natural  rhythm.  Signs  of 
great  irritability  of  the  nervous  system  are  rare,  at  this  early  period  of  the 
illness,  although  in  exceptional  cases  the  disease  may  be  ushered  in  by  a 
convulsive  seizure.  Still,  there  are  sufficient  indications  of  nervous  agita- 
tion. The  senses  are  excessively  acute,  the  pupils  are  contracted,  and  light, 
is  painful  to  the  eyes  ;  the  child  is  distressed  by  loud  noises  ;  and  hyper- 
sesthesia  of  the  skin  may  be  present  so  that  a  touch  is  painful.  During 
this  stage  the  urine  is  scanty  and  may  contain  excess  of  phosphates. 

Of  these  symptoms  the  most  important  are  the  combination  of  head- 
ache, vomiting,  and  confined  bowels,  with  irregular  breathing.  Even  if  the 
latter  be  absent,  the  occurrence  of  vomiting  and  obstinate  constipation 
with  headache  in  a  child  who  for  some  weeks  has  shown  signs  of  failing 
nutrition  is  always  to  be  regarded  with  anxiety. 

In  the  second  stage — the  stage  of  irritation — the  symptoms  become 
more  aggravated.  The  headache  increases  in  severity,  and  the  child  often 
becomes  delirious.  He  lies  in  his  bed  with  his  eyes  closed — often  squeezed 
together,  and  his  eyebrows  contracted — making  chewing  movements  with 
his  jaws  or  grinding  his  teeth  loudly.  Sometimes  he  screams  out  as  if  in 
pain.  If  called,  the  child  usually  opens  his  eyes,  but  he  answers  questions 
unwillingly  or  stares  at  the  speaker  angrily  and  makes  no  attempt  to  reply. 
Whether  from  headache  or  irritability,  the  eyebrows  often  have  a  scowl 
which  gives  a  peculiarly  forbidding  expression  to  the  face  of  the  patient. 

The  pulse  generally  falls  in  frequency  at  this  stage  and  becomes  inter- 
mittent. It  varies  in  rapidity  from  60  to  80,  and  the  finger  pressing  the 
artery  finds  the  rhythm  of  the  pulsations  interrupted  at  irregular  intervals 
by  the  complete  omission  of  one  beat.  It  is  important  in  examining  the 
pulse  in  these  cases  to  seize  an  opportunity  when  the  child  is  lying  quietly 
and  has  not  recently  made  a  movement ;  for  a  pulse  which  is  slow  and  ir- 
regular during  repose  may  become  quick  and  regular  for  a  time  upon  the 
slightest  change  of  position.  The  temperature  is  generally  lower  by  a  de- 
gree than  in  the  first  stage,  and  may  I'ise  no  higher  than  99°.  The  respi- 
rations continue  irregular  as  before,  and  often  at  this  time  assume  the 
Cheyne-Stokes  type.  The  pupils  now  become  dilated  and  are  often  slug- 
gish. Sometimes  there  is  a  slight  squint,  but  this  is  seldom  more  than  a 
passing  deviation.  Examination  by  the  ophthalmoscope,  if  it  can  be  man- 
aged, shows  a  congested  state  of  the  retinal  vessels  and  disk,  and  some- 
times small  bodies  like  gray  granulations  can  be  seen  projecting  from  the 
sides  of  the  small  retinal  arteries.  Towards  the  end  of  this  stage  the 
vomiting  usually  ceases,  but  the  constipation  continues,  and  the  child 
shows  no  desire  even  for  liquids.  There  is  often  retention  of  urine,  and  the 
motions  are  passed  in  the  bed  after  an  aperient.  The  pulse  generally 
quickens  again,  and  the  temperature  rises.  The  abdomen  usually  becomes 
markedly  retracted,  but  still  remains  soft,  doughy,  and  compressible.  Be- 
sides, a  singular  tendency  to  flushing  of  the  skin  is  noticed.  The  cheeks 
suddenly  become  red,  then  the  flush  dies  away  leaving  them  apparently 
whiter  than  before.  Slight  pressure  on  the  skin,  especially  of  the  face, 
abdomen,  and  front  of  the  thighs,  produces  a  bright  redness — the  "  cere- 
bral flush  "  of  Trousseau,  which  remains  visible  for  a  considerable  time. 

The  principal  symptoms  of  this  stage  are  the  fall  in  the  pulse  and  tem- 
perature, the  ajDathy  and  drowsiness  of  the  child,  the  violent  headache,  the 
irregrdarity  of  breathing,  the  excavation  of  the  abdomen,  the  dilatation  of 


360  DISEASE   IlSr   CHILDEEN.    ■ 

the  pujjils,  and  the  passing  strabismus.  The  cerebral  flush,  unless  very  vivid, 
is  an  uncertain  symptom,  for  it  is  often  well  marked  in  cases  where  there  is 
no  reason  to  suspect  tubercular  inflammation  of  the  cerebral  meninges. 

In  the  third  stage  the  temperature  gradually  rises  again,  and  towards 
the  end  may  attain  a  high  elevation.  The  pulse  also  increases  in  rapidity 
and  becomes  regular,  but  the  irregularity  of  breathing  continues.  The 
most  prominent  symptoms  of  this  stage  are  the  increasing  coma  and  the 
occui'rence  of  convulsions  and  paralysis.  The  child,  who  before  could  be 
roused  by  loud  calling,  now  makes  no  sign  of  response,  or  if  for  a  mo- 
ment he  raises  the  lids,  he  closes  his  eyes  again  almost  immediately.  The 
aspect  of  the  child  at  this  period  is  often  very  characteristic  ;  for  if,  as 
often  happens,  the  disease  have  been  j)receded  by  few  signs  of  ill-health, 
and  the  patient  have  retained  his  plumpness,  he  presents  to  the  unedu- 
cated eye  the  appearance  of  a  healthy  child  in  quiet  slumber.  His  cheeks 
are  brightly  flushed,  his  countenajice  perfectly  placid,  his  features  rounded 
as  in  health ;  but  it  will  be  noticed  that  the  eyelids  close  imperfectly,  and 
that  the  respirations  are  very  irregular  and  disturbed  by  deep  sighs  and 
long  pauses.  On  raising  the  eyelids  with  the  finger  the  pupils  are  seen 
to  be  widely  dilated,  they  act  sluggishly  or  not  at  all,  and  are  often  un- 
equal in  size.     There  may  be  nystagmus  or  a  distinct  squint. 

When  the  coma  becomes  complete,  the  flush  usually  subsides  and  the 
face  becomes  very  pale.  The  insensibilitj^  is  not,  however,  always  pro- 
found. Often  it  varies  in  degree,  and  the  child  may  seem  to  wake  up  for 
a  time  and  look  roimd  with  some  intelligence  in  his  glance.  StUl,  it  is 
difficult  to  say  whether  at  these  times  he  is  always  conscious.  In  some 
cases  the  stupor  clears  off  complete^  for  some  hours,  and  the  child  may 
sit  up,  apparently  infinitely  improved,  and  again  show  some  interest  in  his 
toys.  These  cases  are  very  distressing  in  their  effect  upon  the  relatives, 
who  had  given  up  the  child  as  hopeless,  but  now  conclude  that  all  danger 
has  passed.  Unfortunately,  if  the  eyes  be  examined,  it  will  be  found  that 
the  pupils  continue  sluggish,  dilated,  and  unequal  in  size ;  the  squint,  if  it 
had  been  jDresent,  stiU  persists,  and  httle  hope  can  be  entertained  that  the 
improvement  will  be  lasting.  After  a  short  interval,  to  the  infinite  grief 
of  the  friends,  the  coma  returns  as  profoundly  as  before,  and  then  con- 
tinues until  the  close. 

Increase  in  the  coma  is  usually  associated  with  effusion  into  the  ven- 
tricles. If  ossification  of  the  cranial  bones  is  still  incomplete,  the  fonta- 
nelle,  when  the  effusion  occurs,  generally  becomes  elevated  and  tense. 
Still,  it  is  important  to  be  aware  that  a  large  effusion  in  the  ventricles  is 
quite  compatible  with  a  level  or  even  a  depressed  fontanelle. 

Convulsive  movements  generally  come  on  early  in  this  stage.  They 
are  often  partial,  and  may  be  confined  to  twitchings  on  one  side  of  the 
face  or  in  one  arm.  Often,  however,  they  are  general  and  more  severe. 
Between  the  seizures  the  joints  are  often  stiff',  and  paralysis  is  more  or  less 
distinctly  marked.  Squinting  of  one  or  both  eyes  is  seldom  absent,  and 
there  is  frequently  ptosis,  but  general  paralysis  of  the  face  is  rarely  seen. 

Loss  of  power  in  the  limbs  usualty  assumes  the  form  of  hemiplegia. 
The  arm  is  sometimes  affected  alone,  but  the  paratysis  is  said  never  to  be 
confined  to  one  leg.  At  the  end  of  this  stage,  when  the  coma  is  com- 
plete, the  head  often  becomes  retracted  upon  the  shoidders,  and  the  tonic 
rigidity  may  affect  the  whole  spine  ;  the  joints  are  stiff ;  there  is  more  or 
less  complete  paralysis  of  one  side  ;  the  pupils  are  dilated  and  unequal ; 
there  is.  squint  of  one  or  both  eyes  ;  the  ej^eballs  often  oscillate  ;  and  tre- 
mors and  twitchings  may  be  noticed  in  the  muscles  of  the  face  and  limbs. 


TUBERCULAE   MENINGITIS — SECONDARY.  361 

Before  death  the  pulse  usually  becomes  very  rapid ;  the  constipation 
is  replaced  by  diarrhoea  ;  aphthse  appear  upon  the  mouth  ;  the  retracted 
abdomen  swells  out  again  with  gaseous  distention  ;  ophthalmia  may  occur, 
and  the  cornea  often  ulcerates ;  there  is  generally  profuse  sweating,  and 
acute  oedema  occurs  in  the  lungs.  On  the  last  day  the  temperature  may 
fall  to  a  subnormal  level  or  may  rise  very  high,  and  sometimes  it  reaches 
a  surprising  elevation.  Thus,  in  a  little  girl,  five  years  of  age,  the  tem- 
perature on  the  morning  before  her  death  was  97. G'^  ;  but  from  that  point 
it  rose  progressively  tlu-ough  the  day  and  night,  until  at  7.45  a.m.  on  the 
following  morning,  the  time  at  which  she  died,  it  was  110°,  and  two  hours 
after  her  death  had  only  sunk  to  107°. 

The  average  duration  of  the  iUness,  counting  from  the  first  day  of 
vomiting,  is  twelve  days.  It  may,  however,  run  a  shorter  course,  and 
sometimes  comes  to  an  end  on  the  sixth  or  seventh  day.  In  other  cases  it 
lasts  over  a  longer  period,  but  is  seldom  prolonged  beyond  the  end  of  the 
third  week. 

The  sequence  of  the  phenomena,  as  given  in  the  preceding  description, 
is  that  ordinarily  met  with  in  cases  of  the  primary  form  of  the  disease, 
but  there  are  occasional  variations  in  the  symptoms  which  it  is  impor- 
tant to  be  aware  of.  Thus,  in  exceptional  cases  the  illness  begins  with 
diarrhoea,  and  I  have  known  the  looseness  to  persist,  with  occasional  inter- 
missions, throughout  the  course  of  the  attack,  although  no  ulceration  was 
present  in  tlie  bowels.  Vomiting,  also,  may  be  a  far  from  prominent 
symptom.  Sometimes  it  is  quite  absent  ;  at  other  times  the  child  vomits 
once  or  twice,  and  not  afterwards.  Again,  the  j)i-^lse  may  be  slow  from 
the  beginning,  or,  on  the  contrary,  may  be  rapid  at  the  onset  and  never 
afterwards  fall  in  frequency.  Still,  as  a  general  rule,  repeated  observa- 
tions will  usually  detect  a  slow  pulse  at  some  period  of  the  illness,  even  if 
it  only  last  a  few  hours.  It  is  always  imjaortant  in  ascertaining  the.  state 
of  the  pulse  to  do  so  at  a  time  when  the  child  is  perfectly  motionless.  The 
headache,  too,  varies  greatly  in  severity.  It  may  be  excessively  severe  or 
comparatively  slight.  The  intolerance  of  light  is  also  a  variable  symptom. 
Sometimes  it  is  extreme.  In  other  cases  the  child  can  bear  the  light  with- 
out apparent  discomfort.  Lastly,  the  temperature  is  not  always  high.  It 
may  be  little  raised  above  the  normal  level,  and  in  most  cases  the  pyrexia 
lessens  at  the  beginning  of  the  second  stage.  Indeed,  at  this  period  the 
reduction  in  the  fever,  together  with  the  diminislied  fretfulness  of  the  pa- 
tient as  he  becomes  more  stupid  and  drowsy,  may  excite  in  the  minds  of 
the  friends  false  hopes  of  improvement.  It  is  generally  the  case  that  the 
fever  is  higher  in  the  third  stage  than  at  an  earher  period.  If  it  rise  to  a 
high  level  in  this  stage  it  is  a  sign  of  ajjproaching  death. 

In  secondary  tubercular  meningitis  the  earlier  symptoms  of  the  special 
lesion  are  masked  by  the  more  general  phenomena  indicative  of  the  suffer- 
ing of  the  whole  system  from  the  tubercular  cachexia.  This  form  of  the 
disease  is  the  shape  the  affection  invariably  takes  in  infants,  and  it  is  not 
uncommon  in  older  children.  In*  these  cases  nutrition  is  always  greatly 
interfered  with.  The  child  is  thin,  weakly,  and  miserable-looking.  He  is 
more  or  less  feverish,  although,  unless  catarrhal  pneumonia  be  present,  the 
temperature  rarely  exceeds  101° ;  has  no  appetite ;  often  vomits ;  and 
appears  to  be  gradually  wasting  away.  Suddenly  he  is  seized  with  a  fit 
of  convulsions.  This  is  followed  by  partial  paralysis  which  involves  some 
of  the  cerebral  nerves,  notably  the  occulo-motor ;  dilated,  sluggish,  and 
often  unequal  pupils  ;  rigidity  of  joints,  and  stupor.  In  this  state  he  hn- 
gers  a  few  days  ;  the  convulsions  are  repeated  ;  the  pulse  is  small  and  rapid; 


362  DISEASE   IN   CHILDEEjS". 

tile  breathing  is  iiTegvilar ;  tlie  abdomen  is  retracted,  and  tlie  cliild  dies 
without  any  return  of  consciousness.  After  death  the  gray  gxanulation  is 
discovered  vridely  chstributed  thi-oughout  the  internal  organs,  and  the 
lungs  as  well  as  the  cerebral  meninges  are  usually  the  seat  of  inflammation. 

The  convulsions  are  often  very  partial  in  these  cases,  and  may  consist 
merely  of  tonic  spasms  affecting  one  or  more  hmbs,  with  squint  or  conju- 
gated de^dation  of  the  eyes.  Sometimes,  also,  there  are  shght  clonic  spasms 
or  faint  tremors,  unilateral  or  hmited  to  one  limb.  The  outbreak  of  the 
head  symptoms  is  often  preceded  by  sighing  or  irregular  breathing,  flat- 
tened abdominal  parietes,  and  shght  twitches  in  the  limbs ;  but  the  slow 
intermittent  pulse,  which  is  such  a  valuable  sign  in  the  diagnosis  of  the  pri- 
mary form,  is  usually  absent.  Often,  before  the  actual  onset  nothing  at  all 
is  noticed  to  give  rise  to  suspicions  of  intracranial  miscliief,  although  our 
knowledge  that  in  every  case  of  acute  general  tuberculosis  affecting  a  very 
yoimg  child  such  s}-mptoms  are  hkely  to  occm-  should  lead  us  to  watch  for 
them  very  narrowly. 

In  infants  the  affection,  when  secondary,  almost  invaiiably  assumes  this 
form,  and  death  usually  follows  within  a  few  days  of  the  occui-rence  of  the 
head  symptoms.  In  older  childi-en  the  coui'se  of  the  secondai-y  form  is 
somewhat  longer,  and,  indeed,  the  symptoms  in  some  cases  may  approach 
nearly  to  the  t^-pe  obseiwed  when  the  disease  is  primary-.  Still,  there  are 
in  most  cases  many  differences.  Deluium  alternating  with,  stupor,  without 
convulsions,  scjuinting,  or  other  form  of  paralysis,  may  be  the  only  sign 
that  the  meninges  are  affected.  Sometimes  there  is  repeated  vomiting, 
with  some  wandering  of  mind  and  intellectual  sluggishness,  so  that  the 
child  seems  not  to  understand  questions  addressed  to  him,  and  when  told 
to  put  out  his  tongue  makes  no  effort  to  obey.  The  disease  may  even 
reach  its  termination  without  any  more  positive  signs  of  intracranial  lesion 
being  noticed.  Indeed,  in  these  cases  the  vai'iations  in  the  symptoms  are 
infinite  ;  but  if  the  existence  of  general  tuberculosis  has  been  ascertained, 
we  shall  be  at  no  loss  to  explain  the  meaning  of  any  new  symptoms  which 
may  arise  from  the  head  at  this  late  period  of  the  illness. 

Many  anomalous  cases  of  secondaiy  tubercular  meningitis  occur  in 
childi'en  suffering  from  cerebral  tubercle.  This  is  a  chi'onic  cUsease  which 
continues  often  for  months,  and  is  accompanied  by  more  or  less  severe 
symptoms  pointing  to  the  brain.  Fever  is  usually  present,  and  sickness 
and  headache,  which  are  characteristic  sjTnptoms  at  the  onset  of  the  menin- 
gitis, are  also  common  in  the  brain  tumoui'.  Consequently  the  recurrence 
of  these  famihar  phenomena  is  often  attributed  to  the  growth,  and  is  sel- 
dom intei'preted  as  indicating  a  new  phase  of  the  iUness.  In  such  cases 
the  early  period  of  the  meningitis  passes  unnoticed,  and  the  comphcation 
is  seldom  recognised  before  the  more  violent  s^-mptoms  which  are  charac-. 
teristic  of  its  third  stage  are  actuaUy  present. 

Diagnosis. — It  is  not  ahvays  easj^  at  the  beginning  of  an  attack  of  tuber- 
cular meningitis  to  speak  positively  as  to  the  natiu-e  of  the  illness.  The 
fii'st  symptoms  are  often  mild  and  apparently  trifling,  and  if,  misappre- 
hending then'  importance,  we  make  hght  of  wliat  eventuaUy  proves  to  be 
a  fatal  disease,  the  mistake  is  one  which  will  be  certainly  remembered  to  our 
disadvantage.'     Vomiting  and  constipation,   especially  if  conjoined  with 

'■  It  is  well  in  all  cases,  even  of  apparently  trifling  febrile  derangement  occnrring  in 
children  of  known  tubercular  tendencies,  to  warn  tlie  parents  that  altliougli  the  case 
appears  to  be  at  present  one  of  trilling  importance,  even  such  casual  disturbances  are 
found  occasionally  to  arouse  the  dormant  tendency  to  mischief  and  to  be  followed  by 
very  serious  consequences. 


TUBEECULAR  MENINGITIS — DIAGNOSIS.  363 

headache,  form  a  very  suspicious  combination,  and  if  these  occur  in  a  deli- 
cate child  or  succeed  to  a  period,  however  short,  of  general  failure  of 
health,  we  should  view  them  with  serious  apprehension.  If  our  suspicions 
are  well  founded,  symptoms  soon  appear  to  give  them  confirmation.  The 
pulse  becomes  slow  and  intermittent,  the  breathing  is  irregular,  the  child 
gets  stupid  and  drowsy,  the  pupils  dilate  and  are  sluggish,  and  there  may 
be  a  shght  squint.  When  this  stage  of  the  disease  is  reached,  there  is 
little  room  for  hesitation.  It  is  j)rincipally  in  cases  where  the  illness  varies 
from  the  normal  type  that  the  beginning  of  the  disease  gives  rise  to  uncer- 
tainty. Vomiting  may  be  absent.  Instead  of  constipation  there  may  be 
looseness  of  the  bowels.  But  still,  if  the  child  is  feverish,  complains  of 
headache,  and  has  a  pinched,  distressed  expression — if  with  even  trifling 
symptoms  he  looks  really  ill,  we  should  never  speak  slightingly  of  his 
condition. 

Tubercular  meningitis  almost  invariably  begins  insidiously,  and  the 
symptoms  have  a  regular  progression.  It  is  seldom  ushered  in  by  a  con- 
vulsive fit,  and  if  such  a  seiziu^e  occur  at  the  beginning,  it  is  rarely 
repeated.  Slighter  signs  of  nervous  disturbance  may,  however,  be  gener- 
ally discovered  by  careful  observation  and  inquiry.  The  child  will  be 
found  to  have  lately  changed  in  character.  From  an  even-tempered  placa- 
ble boy,  he  has  become  suddenly  irritable  and  spiteful ;  if  natiu'aUy  head- 
strong and  independent,  he  turns  strangely  timid  and  affectionate,  and  is 
moved  to  tears  by  a  kind  word.  Often  he  grows  curiously  silent  and  un- 
willing to  play  or  even  to  speak.  Again,  he  may  be  noticed  to  frown  often 
and  avoid  the  hght.  He  fiushes  frequently,  sighs  deeply,  and  comjDlains  of 
headache  and  giddiness.  All  these  small  details  assume  great  value  if 
combined  with  feverishness,  vomiting,  and  a  look  of  care.  Drowsiness  is 
an  early  symptom,  and  when  succeeding  to  the  above  is  very  suspicious. 
At  the  same  time  the  breathing  generally  becomes  unequal,  with  long 
pauses  and  deep  sighs,  and  this,  itself  an  important  symptom,  becomes  of 
double  value  when  associated  with  others  pointing  in  the  same  direction. 
If  now  the  pulse  falls  in  frequency  and  is  intermittent,  without  improve- 
ment in  other  symptoms,  the  evidence  it  supj)lies  may  be  considered  con- 
clusive. 

The  early  period  of  tubercular  meningitis  may  be  mistaken  for  any  of 
the  other  lesions  or  derangements  which  are  accompanied  by  loss  of  flesh, 
vomiting,  headache,  and  signs  of  nervous  excitement. 

The  condition  called  spurious  hydrocephalus,  which  sometimes  occurs 
in  exhausted  infants  as  a  result  of  anaemia  of  the  brain,  with  sluggish  cere- 
bral ch^culation,  and  is  sometimes  a  sign  of  thrombosis  of  the  cranial 
sinuses,  is  usually  readily  distinguished  by  the  history  of  severe  vomiting 
or  diarrhoea,  the  evident  exliaustion  of  the  cliild,  the  depressed  fontanelle, 
and  the  normal  or  even  subnormal  temperature.  This  condition  is  seldom 
seen  after  the  first  year  of  life,  and  therefore  is  more  likely  to  be  mistaken 
for  a  general  tuberculosis  with  secondarj^  meningitis  than  for  the  primary 
form  of  the  disease.  Sometimes  older  children  after  an  attack  of  serious 
acute  disease  may  be  left  in  a  state  of  profound  malnutrition,  in  which  all 
food  excites  vomiting,  and  the  stomach  seems  incapable  of  retaining  or 
digesting  even  the  simplest  articles  of  diet.  The  child  is  restless  and  fret- 
ful, and  complains  of  headache.  His  skin  ceases  entirel}"  to  act,  is  dry  and 
rough,  and  the  hardened  epithelial  scales  can  be  brushed  off  as  a  fine  dust. 
His  lips  are  dry  and  cracked,  his  bowels  confined,  and  his  urine  scanty  and 
high  coloured.  After  a  time  the  child  becomes  drows}^  and  sinks  into  a 
stupor  in  which  he  dies.     In  these  cases  the  brain  and  the  internal  organs 


364  DISEASE  IN  CHILDEEN. 

generally  are  bloodless  and  wasted.  A  distinction  from  meningitis  may 
usually  be  made  by  the  low  temperatui-e,  which  even  in  the  rectum  is 
often  no  higher  than  97°;  the  history  of  the  case,  the  absence  of  retrac- 
tion of  the  belly,  and  the  coui-se  of  the  illness,  which  has  not  the  regular 
progi'ession  pecuhar  to  the  tubercular  disease. 

An  acute  catarrhal  condition  of  the  stomach  in  a  scrofulous  child  some- 
times presents  symptoms — feverishness,  vomiting,  headache,  and  constipa- 
tion— which  may  be  mistaken  for  the  onset  of  tubercular  meningitis,  more 
especially  as,  when  convalescence  begins,  the  pulse  often  gets  slow  and 
intermittent.  But  in  all  derangements,  as  distingaiished  from  grave  dis- 
eases, there  is  an  important  distinguishing  mark,  viz.,  that  the  patient  does 
not  look  seriously  ill.  If  he  be  not  profoundly  depressed  by  the  severity 
of  the  symptoms,  or  harassed  with  pain,  his  face  is  placid  and  shows  no 
signs  of  distress.  Moreover,  his  breathing  is  regular,  and  his  abdomen 
normal  in  appearance  and  not  retracted.  If,  later,  the  pulse  becomes  slow 
and  intermittent,  the  slackening  coiacides  with  an  improvement  in  the 
symptoms  and  not  vnth  an  unfavoui'able  change  in  the  condition  of  the 
patient. 

Still,  even  a  child  suffering  fi'om  tubercular  meningitis  has  not  always 
a  haggard,  careworn  look.  Some  time  ago  I  saw,  with  Dr.  3Iiller,  of  Black- 
heath,  a  httle  boy,  four  years  old,  who  had  been  noticed  to  be  getting  thin 
and  pale  for  six  weeks.  He  was  often  found  asleep  on  the  floor  in  the 
middle  of  his  play.  He  flushed  up  at  times  and  was  very  fretful,  ciying 
without  cause. 

On  November  18th  he  began  to  vomit,  and  the  sickness  continued 
all  thi'ough  the  week.  It  occiiiTed  usually  about  an  hour  after  food,  and 
seemed  generally  to  be  induced  by  movement.  The  bowels  were  confined, 
but  acted  readily  after  aperients.  The  temperature  at  night  was  about 
100°. 

When  I  saw  the  child,  on  November  25th,  he  was  lying  in  bed,  with  a 
sHght  flush  on  his  cheeks.  His  pulse  was  at  fii-st  100,  and  regTdar  ;  after- 
wards 80,  and  shghtly  intermittent ;  respirations,  26,  and  someAvhat  iiTegn- 
lar,  for  the  child  occasionally  heaved  a  deep  sigh,  although  his  breathing 
was  never  quite  arrested.  Temperatui-e  (at  3  p.ii.)  98.4"^  ;  eyes  bright ;  no 
squint ;  pupils  noi'mal,  and  acted  perfectly  ;  no  j)hotoj)hobia  ;  no  cerebral 
flush  ;  consciousness  perfect,  and  the  boy  answered  questions  readily.  He 
said  that  his  head  sometimes  ached  at  the  back.  Tongue  furred,  white  ; 
motions,  after  aperients,  of  normal  appearance  and  contained  no  mucus  or 
worms.  The  belly  was  deeply  hollowed,  and  the  j)arietes  were  soft, 
doughy,  and  compressible  ;  the  Hver  and  spleen  were  of  normal  size,  and 
the  physical  signs  of  his  heart  and  lungs  were  healthy.  There  was  no  al- 
bumen in  his  urine. 

In  this  case  which  was  seen  on  the  seventh  day  of  the  disease,  the  gen- 
eral mildness  of  the  symptoms,  especially  the  slightness  of  the  headache 
and  the  complete  clearness  of  mind  of  the  chUd  at  so  long  a  period  after 
the  beginning  of  his  illness,  seemed  to  tell  against  tubercular  meningitis  ; 
but  the  history  of  the  case,  the  pulse,  the  sighing  breathing,  the  deeply 
excavated  abdomen,  the  absence  of  sufficient  signs  of  digestive  derange- 
ment to  account  for  his  state,  and  the  want  of  elevation  in  the  temperature, 
which  excluded  a  continued  fever — all  these  symptoms  taken  together 
pointed  \evj  strongly  in  favour  of  the  tubercular  disease  ;  indeed  in  a  few 
days  the  child  became  comatose,  and  he  died  shortly  afterwards. 

"Cerebral  pneumonia "  may  be  accompanied  by  symptoms  which  re- 
semble tubercular  meningitis ;  and  as  the  physical  signs  of  the  chest  may 


TUBEECULAE  MEI^ITiTGITIS — DIAGNOSIS — TEEATMENT.        365 

be  normal  on  the  first  examination,  it  is  often  difficult  at  once  to  distin- 
guish the  real  nature  of  the  disease.  There  is  often  delirium  and  stujjor  ; 
vertigo  may  be  a  jDrominent  symptom  ;  and  the  pulse,  although  rapid,  is  in- 
termittent. In  such  a  case  the  historj^,  the  absence  of  prodromata,  the  per- 
verted pulse-respu'ation  ratio,  the  greater  elevation  of  temperatui-e,  and  the 
early  occurrence  of  the  head  symptoms  are  not  in  favour  of  tubercular 
meningitis ;  but  until  signs  of  consolidation  are  discovered  we  cannot  ven- 
ture positively  to  exclude  meningeal  tubercle. 

In  special  cerebral  disease  the  course  is  usually  very  different  from 
that  of  tubercular  meningitis,  as  the  illness  almost  invariably  begins  ■v\ith 
violent  nervous  symptoms.  The  phi'enitic  form  of  simple  meningitis  of  the 
convexity  approaches  most  nearly  to  tubercular  basic  meningitis  in  its  at- 
tendant phenomena  ;  but  here  the  early  symptoms  are  far  more  severe 
than  in  an  ordinary  case  of  the  tubercular  variety.  The  disease  breaks  out 
suddenly  with  violent  headache,  almost  immediately  followed  by  loud, 
often  furious  dehiium  ;  the  temperature  is  veiy  high  fi-om  the  first ;  stupor 
quickly  supervenes,  and  the  whole  course  of  the  disease  is  rapid. 

In  the  secondaiy  form  of  the  tubercular  disease  the  earliest  sign  of  the 
occurrence  of  the  cerebral  comphcation  is  usually  vomiting,  and  this  sjnnp- 
tom  should  never  be  disregarded.  Often,  however,  the  intra-cranial  in- 
flammation may  first  reveal  itseK  by  a  fit  of  con^vnilsions  or  a  squint.  In  a 
child  who,  after  a  period  of  wasting  and  general  illness,  has  an  attack  of 
catarrhal  pneumonia  in  which  he  is  suddenly  taken  with  a  convulsive  seiz- 
ure,  the  presence  of  a  secondary  tubercular  meningitis  may  be  more  than 
suspected. 

A  basic  meningitis  is  sometimes  seen  in  infants  as  a  consequence  of  in- 
herited syphilis.  The  symptoms  are  identical  with  those  of  the  tubercular 
form  ;  but  the  natiu'e  of  the  illness  may  be  sometimes  inferred  from  the 
appearance  of  the  child  and  the  presence  of  other  signs  of  the  congenital 
malady. 

Cases  ai'e  sometimes  seen  in  which  a  child  dies  with  aU  the  signs  of  a 
tubercular  meningitis,  although  after  death  no  ajDjoearance  of  intracranial 
inflammation  or  exudation  can  be  discovered,  nor  can  the  closest  examination 
detect  any  gray  granulations  either  in  the  skull  cavity  or  at  any  other  part 
of  the  body.  Such  cases  occur  now  and  then  in  most  children's  hospitals.  I 
have  seen  one  or  two  ;  and  as  far  as  I  know  the  form  of  tubercular  men- 
ingitis thus  simulated  is  always  the  secondaiy  form  ;  i.e.,  the  cerebral 
symptoms  do  not  arise  suddenly  in  an  apparently  healthy  child,  but  come 
on  towards  the  close  of  a  more  or  less  prolonged  febrile  attack. 

Prognosis. — Tubercular  inflammation  of  the  cerebral  meninges  is  so 
mortal  a  disease  that  when  the  natvu-e  of  the  case  is  established  beyond  a 
doubt,  a  fatal  termination  is  ine-v^table.  The  disease  is  said  to  have  been 
sometimes  aiTested  before  the  second  stage  had  been  reached.  In  such  a 
case  it  is  reasonable  to  doubt  the  accuracy  of  the  diagnosis.  Probably 
many  of  the  cases  in  which  recovery  from  a  basic  meningitis  has  been 
recorded  have  been  instances  of  the  syphilitic  form  of  the  intracranial 
inflammation,  which  is  much  more  amenable  to  treatment. 

Treatment. — The  disease  is  so  fatal  when  once  established  that  specitil 
precautions  should  be  taken  in  every  case  where  we  have  ascertained  the 
existence  of  the  tubercular  diathesis  to  prevent  the  development  of  the 
cachexia,  and  ward  off  all  influences  tending  to  promote  irritation  and  con- 
gestion of  the  brain.  For  the  general  means  to  be  adopted  to  strengthen 
the  constitution  and  weaken  the  diathetic  tendency  the  reader  is  referred 
to  the  chapter   on  tuberculosis.      With  regard  to  special  measures,  we 


366  DISEASE  IN   CHILDRE1S-. 

should  be  careful  to  forbid  the  more  exciting  amusements  and  too  boister- 
ous games.  The  mind  of  the  child  should  not  be  overtaxed  with  protracted 
study,  and  care  should  be  taken  that  his  intervals  of  relaxation  are  frequent 
and  regular. 

"When  the  disease  is  actually  established,  we  can  have  little  hope  that 
any  treatment  we  can  adopt  will  succeed  in  checking  the  course  of  the 
illness.  The  violent  measures  which  it  was  at  one  time  thought  necessary 
to  employ  in  cases  of  tubercular  meningitis  have  been  found  to  be  not 
only  useless  but  actually  hurtful.  Few  judicious  practitioners  would  now 
think  of  applying  leeches,  of  blistering  the  skin,  of  running  a  seton  into 
the  neck,  or  of  rubbing  tartar  emetic  ointment  into  the  shaven  scalp.  If 
the  case  be  seen  early,  perfect  quiet  in  a  room  carefully  shaded  from  the 
hght  should  be  enforced  ;  ice-bags  should  be  applied  to  the  head,  and  the 
feet  should  be  kej)t  warm.  The  bowels  must  be  relieved  by  a  dose  of  calo- 
mel and  jalapine,  or  compound  scammony  powder,  and  in  the  hope  that  the 
disease  may  have  a  syphilitic  origin,  the  perchloride  of  mercury,  in  doses 
of  fifteen  to  thirty  drops,  can  be  given  two  or  three  times  a  day.  The  child 
should  be  supplied  with  liquid  food  in  sufficient  quantities  ;  and  if  he  re- 
fuse to  swallow,  he  must  be  fed  through  an  elastic  catheter  passed  down 
the  gullet.     Stimulants  must  be  given  as  seems  necessary. 


CIIAPTEE  XY. 

PAKALYSIS  OF   THE   POETIO   DURA. 

Facial  paralysis  from  aifection  of  the  portio  dura  of  the  seventh  nerve 
may  be  a  mild  or  severe  complaint  according  to  the  cause  on  which  the 
paralysis  depends.  It  is  common  enough  in  children,  and  in  them  is  fre- 
quently a  sign  of  severe  and  perhaps  inciu'able  disease. 

It  will  be  remembered  that  the  facial  nerve  rises  in  the  floor  of  the 
fourth  ventricle  from  a  nucleus  common  to  it  and  the  sixth  nerve.  Thence 
it  passes  outwards  with  the  auditory  neiwe,  enters  the  internal  auditory 
meatus,  and  is  conveyed  by  the  Fallopian  aqueduct  to  its  foramen  of  exit 
from  the  skull.  It  is  important  to  bear  in  mind  the  principal  branches 
given  off  by  the  nerve  in  the  Fallopian  canal,  as  the  seat  of  the  lesion  is 
determined  by  the  extent  and  distribution  of  the  paralysis.  Shortly  after 
entering  the  aqueduct,  the  facial  nerve  is  joined  by  the  large  superficial 
petrosal  branch  of  the  Vidian  nerve.  It  is  by  this  channel  that  it  conveys 
nervous  influence  to  the  velum  ;  for  the  Vidian  nerve  is  united  with  Meck- 
el's ganglion,  from  which  branches  descend  to  supply  the  muscles  of  the 
uvula  and  soft  palate.  Soon  afterwards  it  is  joined  by  the  small  super- 
ficial petrosal  branch  from  the  tympanic  nerve  ;  and  a  little  farther  on  it 
gives  off  the  chorda  tympani,  which  joins  the  gustatory  branch  of  the  fifth 
nerve,  and  is  distributed  to  the  tongue. ' 

Causation. — The  function  of  the  facial  nerve  may  be  interfered  vdth  by 
a  lesion  at  any  part  of  its  course,  from  its  origin  in  the  floor  of  the  fourth 
ventricle  to  its  j)eriphery.  The  cause  of  the  paralysis  may  therefore  lie  in- 
side the  skull  cavity,  in  the  Fallopian  aqueduct,  or  outside  the  temporal 
bone. 

Inside  the  skull  the  nerve  may  be  injured  by  extravasation  of  blood  or 
be  compressed  by  tumours,  inflammatory  thickenings  of  the  dura  mater, 
and  by  exudations.  In  the  Fallopian  canal  the  nerve  may  be  damaged  by 
fracture  at  the  base  of  the  skull,  or  be  destroyed  by  caries  of  the  petrous 
bone.  After  leaving  the  temporal  bone  the  nerve  may  be  injured  by  the 
forceps  during  delivery  ;  or  by  blows  upon  the  face  ;  or  by  inflammation 
set  up  in  its  sheath  by  extension  from  neighbouring  parts,  as  in  parotid- 
itis ;  or  by  an  impression  of  cold,  causing  rheumatic  inflammation  of  the 
sheath  of  the  nerve. 

The  two  chief  causes  which  give  rise  to  this  condition  in  children  are, 
no  doubt,  carious  disease  of  the  petrous  bone,  and  exposure  of  the  face  to 
a  current  of  cold  air.  Of  these  the  first  is  a  very  serious  disease,  the  sec- 
ond a  comparatively  trifling  one. 


'  According  to  some  anatomists  the  chorda  tympani  is  derived  from  the  nerve  of 
Weisberg,  and  not  from  the  facial.  It  is  intimately  connected  with  the  lingual  branch 
of  the  fifth  ;  and  the  sense  of  taste  in  the  anterior  two-thirds  of  the  tongue  is  depend- 
ent entirely  upon  the  chorda  tympani,  the  lingual  presiding  over  general  sensibility 
only. 


368  DISEASE  IN   CHILDKElSr. 

Caries  of  the  petrous  part  of  tlie  temporal  bone  is  a  common  conse- 
quence of  neglected  otitis  in  the  child.  According  to  Von  Troltsch,  it  is 
far  from  uncommon  to  find  the  mastoid  cells,  with  the  tympanic  cavity, 
and  the  Eustachian  tube  the  seat  of  suppui-ative  cataiTh  in  a  child  who 
had  hved  and  died  without  the  disease  having  been  suspected.  This  con- 
dition may  exist  "without  external  discharge,  without  jDain,  or  any  symptom 
by  which  its  presence  may  be  revealed  (see  Otitis). 

In  childi'en  under  three  years  of  age  facial  paralysis  is  not  rare.  At 
this  time  of  life  it  is  due  almost  invariably  to  otitis  and  caries  of  bone,  with 
suppuration  in  the  sheath  of  the  nerve.  Older  children  may  suffer  from 
paralysis  arising  from  tlie  same  cause,  but  in  them  there  is  increasing  jprob- 
abihty  that  the  los-s  of  power  is  the  consequence  of  a  chill 

Symptoms. — The  first  sjTaptom  usually  noticed  by  the  mother  is  that 
the  child's  mouth  is  drawn  to  one  side  when  he  laughs,  or  cries.  On  care- 
ful inspection  it  will  be  found  that  the  absence  of  movement  involves  the 
whole  side  of  the  face.  "While  the  features  are  at  rest,  the  eye  on  the  af- 
fected side  is  incompletely  closed  ;  the  nostril  is  flattened  ;  the  cheek  may 
hang  a  httle,  although  this  is  not  easy  to  detect  in  babies  ;  and  the  angle 
of  the  mouth  is  slightly  lowered.  It  is  when  the  child  cries  that  the  great 
difference  between  the  two  sides  is  seen.  Then,  on  the  healthy  side  the 
eyebrow  contracts  ;  the  forehead  wrinkles  ;  the  eye  closes  ;  the  ala  of  the 
nose  and  the  mouth  are  drawn  upwards  ;  and  the  middle  line  of  the  Hjds  is 
pulled  far  out  of  the  centre  of  the  face.  On  the  affected  side,  on  the  con- 
trary, the  muscles  are  motionless ;  the  eye  is  open  ;  and  the  skin  remains 
smooth.  If  the  nerve  is  affected  in  the  FalloiDian  canal,  the  paralysis  af- 
fects the  soft  palate.  On  looking  into  the  throat,  it  will  be  seen  that  on 
the  side  of  the  lesion  the  arch  of  the  palate  is  flattened,  and  that  the  uvula 
is  curved  to  the  sormd  side  ;  for  the  motor  fibres  which  pass  through  the 
large  superficial  petrosal  nerve  and  the  Vidian  neiwe  to  Meckel's  ganghon. 
from  which  the  palatine  branches  proceed,  contract  the  azygos  uvulae  only 
on  the  sound  side.  For  the  same  reason  childi-en  may  complain  that  theii' 
mouth  is  dry  and  their  taste  impaired — the  chorda  tympani,  which  erects 
the  papillae  of  the  tongue  and  promotes  secretion  of  saliva,  no  longer  con- 
veying the  nervous  influence.  Sensibihty  is  not  affected,  but  babies  often 
seem  to  have  a  difficulty  in  swallowing  theu*  food  ;  and  if  there  should  be 
loss  of  power  on  one  side  of  the  soft  palate, ,  some  of  the  milk  may  be  oc- 
casionally retui'ned  through  the  nose.  An  older  child  comjDlains  of  great 
inconvenience  fi'om  food  collecting  between  the  g-ums  and  the  cheek, 
thi'ough  the  action  of  the  buccinator  being  paralysed.  He  can  no  longer 
whistle,  and  even  his  speech  may  be  impau'ed.  The  half-open  eye  is  apt 
to  become  inflamed  from  exposiire  ;  and  there  may  be  a  flow  of  tears  over 
the  cheek  as  a  consequence,  according  to  Duchenne,  of  paralysis  of  the 
tensor  tarsi  muscle,  which  no  longer  retains  the  puncta  in  its  normal  posi- 
tion. 

The  s^TQijDtoms  which  are  produced  by  a  lesion  affecting  the  facial  nerve 
in  the  Fallopian  aqueduct  are  well  seen  in  the  following  case  : 

A  little  girl,  aged  sixteen  months,  was  admitted  into  the  East  London 
Childi'en's  Hospital  on  March  24:th.  The  mother  stated  that  the  child 
had  been  always  healthy  until  two  weeks  previously,  when  she  had  begun 
to  be  feverish  and  to  beii'ritable  and  thirsty.  For  the  same  time  she  had  been 
losing  flesh  and  had  had  some  cough.  The  day  before,  while  sitting  up  in 
her  mother's  arms,  the  child  had  suddenty  fallen  backwards  in  a  fainting 
condition,  and  had  seemed  to  lose  consciousness.  It  was  then  noticed  that 
her  face  was  drawn  to  the  right.     On  admission  there  was  found  complete 


FACIAL   PAKALYSIS — SYMPTOMS.  369 

paralysis  of  the  left  side  of  the  face,  and  the  left  eye  closed  incompletely. 
The  uvula  was  small  and  showed  no  distortion.  A  discharge  escaped  from 
the  left  ear,  but  the  mother  could  not  say  how  long  this  had  been  going 
on.  On  examination  of  the  chest  there  was  impaired  resonance  at  each 
apex,  and  the  breathing  was  high-pitched  and  bronchial,  with  a  large 
bubbling  rhonchus.  Over  both  sides  of  the  chest  dry  and  moist  rales  were 
heard.  During  the  first  fortnight  of  the  child's  residence  in  the  hospital  her 
temperature  varied  between  99°  and  100°.  She  took  her  food  fairly  well,  but 
seemed  to  swallow  with  difficulty,  and  occasionally  fluids  returned  through 
the  nose.  The  paralysis  of  the  face  continued,  and  the  left  eye  became 
red  and  congested.  The  otorrhoea  improved  ;  but  the  child's  temperatui'e 
became  higher,  and  rose  to  104.5°  in  the  evening.  Then  the  left  cornea 
sloughed,  and  the  patient  died  suddenly  on  April  19th. 

After  death  both  lungs  were  found  studded  over  with  small  cheesy 
masses.  On  examination  of  the  left  ear  the  tympanic  membrane  was  de- 
stroyed ;  the  OGsicles  were  carious  and  broken  down  ;  the  tympanum  and 
mastoid  cells  were  filled  with  pus  ;  the  wall  of  the  tympanum  was  carious, 
and  a  probe  could  be  passed  though  it  in  the  direction  of  the  Fallopian 
canal.  There  was  no  inflammation  of  the  brain  or  its  membranes.  The 
cranial  sinuses  were  not  examined. 

Tiie  occurrence  of  the  paralysis  is  not  always  attended  with  symptoms 
of  shock,  as  in  the  above  instance.  Usually  it  is  only  discovered  acci- 
dentall}'  by  noticing  a  deviation  in  the  child's  face  when  it  cries.  The 
sloughing  of  the  cornea  in  the  case  narrated  was  due  to  implication  of  the 
sensory  branch  of  the  fifth  nerve. 

In  the  parts  supplied  by  the  paralysed  facial  nerve  the  loss  of  power 
is  usually  complete  ;  and  if  the  lesion  affect  the  nerve  after  its  passage 
through  the  internal  auditory  meatus — that  is  to  say,  if  the  facial  nerve 
and  no  other  be  implicated,  the  motion  of  the  tongue  is  unimpaired,  the 
muscles  of  mastication  act  well,  and  there  is  no  loss  of  power  in  the  levator 
palpebrse  or  the  muscles  of  the  eyeball.  In  aU  but  the  mildest  forms  the 
paralysed  muscles  soon  lose  their  irritability,  and  cease  to  respond  to  the 
electric  current. 

When  the  paralysis  is  due  to  caries  of  the  petrous  bone  there  is  usually 
discharge  from  the  meatus  of  a  very  offensive  kind,  and  more  or  less  im- 
pairment of  hearing.  When  the  cause  of  the  loss  of  power  is  inside  the 
skull  cavity,  we  get  signs  indicating  the  involvement  of  other  nerves. 
There  is  squinting,  or  deafness,  or  anaesthesia,  and  hemiplegia  may  be  pres- 
ent. Occasionally  it  happens  that  paralysis  of  the  sensory  branch  of  the^ 
fifth  nerve  accompanies  the  facial  paralysis.  If  this  nerve  be  affected  at  a. 
point  anterior  to  the  Gasserian  ganglion,  where  it  lies  on  the  petrous  part. 
of  the  temporal  bone,  there  result  loss  of  sensibility  of  that  side  of  the 
face,  of  the  conjunctiva,  and  of  the  anterior  portion  of  the  tongue,  also,, 
inflammation  of  the  conjunctiva,  and  ulceration  of  the  cornea.  If  the  nerve 
be  affected  at  a  point  posterior  to  the  Gasserian  ganghon,  inflammation 
and  ulceration  of  the  cornea  do  not  follow,  although  the  sensibility  of  the 
face  is  still  affected.  If  the  portia  dura  be  diseased  at  its  origin  in  the 
nucleus  common  to  it  and  the  sixth  nerve,  internal  strabismus  from  paralysis 
of  the  external  rectus  muscle  of  the  eyeball  will  accompany  the  facial  palsy. 

Diagnosis  and  Prognosis. — If  the  paralysis  is  noticed  directly  after  birth 
in"  a  child  who  has  been  delivered  with  instruments,  the  cause  of  the  in- 
firmity is  evident  and  the  prognosis  most  favourable.  In  older  babies  and 
young  children  it  is  veiy  important  to  discover  the  seat  of  the  lesion.  K 
it  is  due  to  caries  of  bone,  and  the  nerve  is  consequently  affected  in  the  Fal- 
24 


370  DISEASE   I2s^    CHILDEEX. 

lopian  canal,  there  is  an  offensive  discliai'ge  from  the  aiiclitoiy  meatus,  and 
the  sense  of  healing  is  more  or  less  blunted.  Perhaps,  also,  "^"e  can  detect 
a  certain  degree  of  flattening  of  the  palatal  arch  on  the  affected  side,  with  a 
httle  twisting  of  the  uvula,  but  this  sign  in  childi'en  whose  uvula  is  small 
is  often  absent.  The  existence  of  impau-ment  or  perversion  of  the  sense 
of  taste  is  also  impossible  to  ascertain  in  young  children.  In  them  old 
standing  otorrhoea,  or  even  a  recent  offensive  discharge  from  the  meatus, 
combined  -with  facial  paralysis,  affords  suspicion  of  the  strongest  kind  that 
the  facial  nei-ve  is  affected  in  the  Fallojoian  aqueduct.  The  prognosis  in 
these  cases  is  very  unfavourable.  In  fact,  death  usually  occurs  sooner  or 
later  from  extension  of  the  inflammation  to  the  dura  mater  and  the  brain. 
The  form  of  facial  palsy  which  is  found  in  children  under  the  age  of  thi-ee 
years  is  commonly  due  to  this  cause.  In  an  older  child,  if  the  j)aralysis 
has  not  been  preceded  by  any  impairment  of  the  sense  of  heai'ing,  or  by 
otorrhoea  ;  if  his  sense  of  taste  is  natural,  his  mouth  perfectly  moist,  and 
his  uvula  straight,  we  may  conclude  that  the  nerve  is  affected  in  the  third 
pai't  of  its  coui'se.  If,  as  usuaUy  hapj^ens  in  such  cases,  there  is  history 
of  exposure  to  cold  or  of  some  slight  injury  to  the  face,  the  prognosis  is 
favoui-able  although  recoveiy  may  take  some  time. 

Treatment. — Facial  i^alsy  from  pressure  of  the  forceps  during  delivery 
soon  disappears,  and  little  treatment  is  requh^ed  beyond  fi-equent  frictions 
to  the  face.  Paralysis  from  cold  should  be  treated  by  steady  frictions  with 
stimulating  liniments,  and  the  affected  side  of  the  face  should  be  wrapped 
up  in  cotton  wool.  Electricity  is  useful.  Dr.  Duchenne's  plan  was  to  em- 
ploy  flrst  the  constant  cuiTent  with  frequent  intermissions,  and  as  the  ir- 
ritabihty  of  the  muscles  retui-ned,  to  make  the  intermissions  less  frec^uent 
and  the  sittings  shorter.  He  never  used  faradism  until  several  weeks  had 
elapsed  after  the  beginning  of  the  paralysis,  although  at  the  later  stage  he 
allowed  its  value.  Under  the  use  of  these  measui'es  the  tonicity  of  the 
muscles  returns,  and  the  face  regains  its  symmetry  some  weeks  before 
voluntaiy  power  is  restored. 

Besides  electricity  and  passive  exercise.  Dr.  W.  A.  Hammond  recom- 
mends the  eaiiy  emplo}-ment  of  strychnia  in  sufficient  doses  to  bring  the 
patient  under  the  full  influence  of  the  drug.  He  also  insists  ujDon  the  im- 
portance of  supporting  the  affected  side  of  the  face  by  means  of  a  little 
hook  placed  in  the  angle  of  the  mouth  and  fastened  to  the  ear.  But  me- 
chanical supports  of  this  kind,  which  depend  for  then-  usefulness  upon  the 
intelligent  co-operation  of  the  patient,  are  not  well  suited  to  young  children. 

In  cases  where  the  palsy  is  due  to  disease  of  bone,  little  can  be  done 
in  the  way  of  treatment.  Our  efforts  must  be  then  dii'ected  entirely  to 
the  cure  of  the  otitis. 


CHAPTEK   XVI. 

ACUTE    INFANTILE    SPINAL    PARALYSIS. 

Acute  infantile  spinal  paralysis,  or  acute  anterior  polio-myelitis,  is  not,  as 
was  formerly  suj^jDosed,  a  disease  peculiar  to  childliood.  It  is  now  known 
to  occur  also  in  adults,  although  in  them  much  more  rarely  than  in  younger 
persons.  This  lesion  constitutes  the  ordinary  form  of  paralytic  affection 
to  which  children  are  liable.  It  nearly  always  begins  in  babyhood — dur- 
ing the  time  of  the  first  dentition — but  often  lasts  long  after  the  first  teeth 
have  been  completed,  and  indeed  may  render  the  child  a  cripple  for  life. 

Tiie  disease  is  never  a  fatal  one  in  itself,  but  if  death  occur  from  other 
causes  in  a  child  so  paralysed,  no  naked-eye  changes  in  the  spinal  cord 
can  be  discovered.  Consec|uentlY  the  nature  of  the  lesion  was  long  doubt- 
ful, and  has  only  recently  been  elucidated.  Now,  however,  owdng  to  the 
researches  of  MM.  Charcot,  Joffroy,  Roger,  Damaschino,  and  others,  the 
loss  of  power  has  been  shown  to  be  due  primarily  to  an  inflammation  af- 
fecting the  gray  matter  of  the  anterior  cornua  of  the  spinal  cord,  causing 
atrophy  and  disappearance  of  the  large  mtiltipolar  ganglion  cells  in  that 
situation.  The  reader  may  be  reminded  that  these  large  ganglion  cells  are 
believed  to  be  centres  of  reflex  action  and  transmitters  of  impulses  received 
through  the  spinal  tracts.  They  therefore  influence  the  movements  of 
muscle.  Besides  this,  they  are  jorobably  trophic  centres  and  regulate  the 
nutrition  of  tissues.  Consequently  the  disappearance  of  these  cells  is  fol- 
lowed by  impairment  or  even  abolition  of  reflex  and  voluntary  action  in  the 
parts  with  which  they  are  in  communication,  and  also  by  impaired  nutrition 
in  muscles,  tendons,  bones,  and  joints. 

Causation. — As  the  disease  is  mainly  limited  to  the  period  of  the  first 
dentition,  cutting  of  the  teeth  has  been  supposed  to  be  a  cause  of  the  mye- 
litis ;  but  if  this  be  the  case  it  is  probably  so  only  indirectly.  An  infant 
feverish  from  teething  is  in  a  high  state  of  nervous  irritability.  His  diges- 
tion is  impaired,  and  his  pyrexia  renders  him  exceptionally  sensitive  to 
chill  and  other  causes  of  inflammatory  and  catarrhal  disorder.  For  this 
reason  pulmonary  and  intestinal  derangements  are  common  at  this  period 
of  life.  But  these  ailments  cannot  be  said  strictly  to  be  caused  by  denti- 
tion, except  in  the  sense  that  the  process  of  teething,  by  making  the  child 
feverish,  heightens  his  susceptibility  to  ordinary  injurious  influences.  So, 
also,  in  the  case  of  this  disease,  an  infant,  when  feverish,  is  more  likely  to 
be  affected  by  causes  which  produce  the  myehtis  than  he  would  be  at  an- 
other time  when  his  temperature  is  normal,  his  digestion  good,  and  his 
nervous  system  undisturbed.  What  these  causes  may  be  is  doubtful.  The 
inflammation  is  often  attributed  to  chills,  and  there  is  no  doubt  that  the 
season  of  the  year  has  a  distinct  influence  in  inducing  the  attacks.  Drs. 
Wharton  Sinkler,  of  Philadelphia,  and  Barlow,  of  Manchester,  have  made  in- 
quiries into  this  matter.  Out  of  one  hundred  and  forty-nine  cases  collected 
by  the  former  physician  no  less  then  seventy-seven  occurred  in  the  months 
of  July  and  August.  In  Dr.  Barlow's  one  hundred  and  eleven  cases  forty- 
eight  occurred  during  the  same  months.     Now  July  and  August,  although 


372  DISEASE  IIST   CHILDREN. 

the  hottest  montlis  in  the  year,  are  also  those  in  which  alternations  of  tem- 
perature are  most  rapid  and  unexpected,  and  in  which,  therefore,  sudden 
chills  are  very  likely  to  be  incurred.  If  the  child  at  the  time  of  the  change 
is  depressed  and  exhausted  by  previous  intense  heat — as  he  is  apt  to  be  in 
a  tropical  climate — the  sudden  lowering  of  the  temperature  is  the  more 
likely  to  produce  an  injurious  effect.  The  disease  sometimes  occurs  after 
typhoid  fever :  Dr.  Buzzard  has  known  it  to  come  on  after  measles  ;  and 
the  paralytic  attack  appeared  in  a  patient  of  my  own — a  little  gui  of  two  and 
a  half  years  old — during  convalescence  from  an  obstinate  chronic  diarrhcea. 
Both  sexes  ajppear  to  be  subject  to  it  in  an  equal  degree  ;  and,  apparently, 
robust  health  is  no  protection  from  its  attacks,  for  it  as  often  affects  a  con- 
stitutionally healthy  child  as  a  cachectic  and  weakly  one. 

Morbid  Anatomy. — The  lesion  is  limited  to  the  spinal  cord,  the  brain 
being  unaffected.  An  inflammatory  process  attacks  the  anterior  cornua 
and  produces  certain  changes  in  the  gray  matter  itself,  in  the  roots  of  the 
nerves  which  take  their  origin  in  this  situation,  and  in  the  muscles,  tendons, 
bones,  and  joints  to  which  they  are  distributed. 

In  the  gray  matter  the  changes  are  not  appreciable  by  the  naked  eye, 
except  that  in  old  standing  cases  a  certain  diminution  in  bulk,  with  increased 
consistence  of  the  affected  parts,  can  be  sometimes  detected.  By  careful 
microscojDic  examination,  however,  the  changes  can  be  distinctty  recognised. 

The  inflammatory  j)rocess  is  diffused  through  the  gray  matter  forming 
the  anterior  horns  ;  but  is  more  intense  at  certain  points,  notably  the 
cervical  and  lumbar  enlargements.  As  a  consequence,  areas  of  softening 
can  be  seen,  more  or  less  sharply  defined,  seated  towards  the  front  of  one 
or  both  cornua.  In  these  areas  the  tissue  is  soft  and  friable,  the  blood- 
vessels are  fuller  than  natural,  and  numerous  granulation  cells  are  seen 
with  an.  increase  in  the  amoiuit  of  connective  tissue.  The  most  striking 
change  consists,  however,  in  the  fact  that  the  large  ganglion  cells  have  almost 
completely  disappeared,  and  the  few  which  are  left  are  greatly  atrophied 
and  degenerated.  The  nerve  fibres  and  axis  cylinders  are  also  destroyed, 
and  the  anterior  roots  are  degenerated  and  wasted.  As  a  consequence  of 
these  changes  the  anterior  horns  look  small  and  shrunken  at  the  spots  where 
these  diseased  foci  are  situated.  Although  the  diseased  process  is  thus 
concentrated  in  certain  patches,  the  gray  substance  generally  is  not  com- 
pletely healthy.  Throughout  the  whole  dorsal  portion  of  the  cord  the 
gray  matter  is  often  more  or  less  affected.  Granulation  cells  may  be  seen 
to  be  scattered  through  the  tissue  ;  the  nuclei  are  multijDlied  ;  the  blood- 
vessels are  dilated   and  ganglion  cells  here  and  there  have  disapj)eared. 

The  above  changes  constitute  the  first  stage — that  of  active  inflamma- 
tion. As  the  acute  process  subsides  improvement  takes  place  in  parts 
where  the  gray  matter  has  not  undergone  entire  destruction.  But  in 
other  regions,  where  the  disintegrating  process  has  been  complete,  further 
changes  ensue.  These  consist  in  a  more  extreme  wasting  and  shrinking  of 
the  anterior  horns,  so  that  the  diminution  in  bulk  becomes  visible  to  the 
naked  eye.  The  disease  is  most  marked  in  the  cervical  and  lumbar 
enlargements.  In  the  affected  areas  there  is  complete  destruction  of  all 
nerve  fibres  and  ganglion  cells.  Even  if  a  few  are  left,  they  are  degener- 
ated and  shrivelled.  The  area  becomes  filled  with  a  fine  fibroid  connec- 
tive tissue,  rich  in  nuclei,  and  the  blood-vessels  are  hypertrophied.  Even 
the  anterior  white  columns  become  more  or  less  degenerated.  Their 
neuroglia  is  thickened,  their  nerve  fibres  are  atrophied,  and  the  develop- 
ment of  the  columns  is  retarded,  so  that  they  look  small  and  narrow. 
This  is,  however,  probably  a  secondary  affection,  and  is  not  necessary  for 


IJVTFANTILE  PARALYSIS — MOEBID  ANATOMY — SYMPTOMS.     373 

the  complete  development  of  tlie  symptoms.  Stated  brie%,  the  lesion 
which  constitutes  infantile  paralysis  may  be  said  to  be  an  acute  myelitis 
of  the  anterior  gray  cornua,  leading  to  circumscribed  patches  of  sclerosis 
with  complete  destruction  of  the  large  ganghon  cells  and  other  nerve 
elements. 

The  changes  which  have  been  described  supply  an  explanation  of  the 
peculiar  phenomena  observed  in  the  disease.  The  striking  limitation  of 
the  paralysis  to  certain  muscles,  or  groups  of  muscles,  and  the  complete 
immunity  of  others,  is  due  to  the  concentration  of  the  lesion  into  certain 
circumscribed  areas  ;  while  the  early  resolution  of  the  inflammation  in  the 
larger  portion  of  the  tissue  attacked  accounts  for  the  disappearance  of  the 
first  severe  symptoms,  and  the  restitution  of  power  in  many  of  the  muscles 
primarily  affected. 

The  paralysed  muscles  also  undergo  atrophy  and  degeneration.  They 
become  at  first  paler  and  softer,  then  grayish  or  reddish  yellow,  with  bands 
of  connective  tissue,  and  yellow  lines  or  streaks  of  fatty  tissue.  The  micro- 
scope shows  at  different  stages  the  fibres  wasted,  and  their  striation  indis- 
tinct, with  hyperplasia  of  the  cells  of  the  sarcolemma  ;  then  the  fibres 
cloudy  with  numerous  fat  molecules  ;  finally,  almost  complete  absence  of 
muscular  fibre.  The  normal  structure  is  often  replaced  by  an  increased 
formation  of  connective  tissue,  so  that  what  was  once  a  muscle  becomes  a 
mere  fibrous  bundle  ;  in  other  cases  we  find  substitution  of  the  normal 
muscular  substance  by  adipose  tissue,  and  by  this  means  the  original 
volume  of  the  muscle  may  be  actually  increased. 

Fatty  degeneration  is  not  an  invariable  consequence  of  the  muscular 
paralysis.  Even  when  it  occurs,  it  is  often  not  universal,  and  proceeds 
much  faster  in  some  bundles  of  fibres  than  in  others. 

The  bones  as  well  as  the  muscles  become  wasted.  Their  development 
and  growth  are  retarded,  and  their  density  diminished. 

Symptoms. — The  attack  is  sudden,  and  the  paralysis  reaches  its  height 
at  once,  both  m  distribution  and  degree.  In  many  cases  the  child  exhibits 
no  symptoms  of  illness.  He  goes  to  bed  to  aU  appearance  perfectly  well. 
In  the  morning  one  or  more  of  his  limbs  is  found  to  hang  loosely  and  to 
be  motionless,  otherwise  he  shows  no  sign  of  ill  health.  In  quite  young 
babies,  who  cannot  walk,  the  loss  of  power  may  remain  unnoticed  for 
several  days.  In  a  second  class  of  cases  the  symptoms  are  a  little  more 
marked.  A  child  who  has  been  put  to  bed  in  his  usual  health  is  seized  in 
the  night  with  fever.  He  cries  and  is  very  restless.  In  the  morning  more 
or  less  extensive  paralysis  is  discovered.  In  a  third  class  of  cases  the  child 
is  feverish  and  poorly  for  several  days  before  the  paralysis  occurs,  some- 
times he  is  delirious,  or  he  may  have  an  attack  of  convulsions  followed  by 
stupor.  In  all  cases,  probably  even  in  those  where  the  symptoms  are  the 
least  accentuated,  there  is  some  preliminary  fever,  but  this  may  last  only  a 
few  houi's,  and  is  often  unnoticed  by  the  attendants. 

The  paralysis  is  complete.  It  may  be  widely  distributed,  or  may  be 
limited  to  one  muscle  or  a  group  of  muscles.  It  may  afiect  all  four  limbs ; 
it  may  attack  only  the  lower  extremities ;  it  may  assume  the  hemiplegic 
form  and  fix  upon  the  arm  and  leg  of  one  side  ;  or,  again,  it  may  settle  upon 
one  limb  only — in  such  a  case  the  right  foot  is  said  to  be  the  part  most 
frequently  selected.     In  this  form  of  paralysis  the  face '  and  parts  sup- 

'  With  regard  to  the  absence  of  paralysis  of  the  face  it  is  right  to  say  that  Dr.  Buz- 
zard has  recorded  a  case  which  appears  to  be  one  of  undoubted  infantile  paralysis  in 
which  facial  paralysis  was  noted.  Dr.  Buzzard  attributes  Ihis  exceptional  phenomenon 
to  an  extension  upwards  of  the  inflammatory  process  into  the  medulla  oblongata.     He 


374  DISEASE  i]sr  childeen. 

plied  by  cerebral  nerves  are  never  affected,  the  intelligence,  after  the  first 
onset,  is  never  impaired,  and  control  over  the  rectum  and  bladder,  at  any 
rate  after  the  first  few  days,  is  never  lost.  Sensibility  in  the  paralysed 
parts  remains  in  every  way  normal ;  there  is  no  pain  anywhere ;  no  rash 
upon  the  skin  ;  no  tendency  to  the  formation  of  sores  or  sloughs  upon 
parts  exposed  to  pressure ;  no  rigidity  of  the  joints.  The  affected  limb  is 
perfectly  flaccid  and  painless,  but  also  perfectly  motionless.  In  some  rare 
cases  the  onset  of  the  disease  has  been  said  to  be  attended  by  pains  in  the 
back  and  limbs,  and  by  hyperaesthesia  of  the  skin  ;  but  these  phenomena 
are  not  directly  the  consequence  of  the  spinal  lesion,  and  form  no  neces- 
sary part  of  the  group  of  symptoms  which  are  held  to  be  characteristic  of 
infantile  paralysis. 

The  flaccidity  of  the  paralysed  muscles  is  accompanied  by  a  loss  of  re- 
flex phenomena  and  a  diminution  or  complete  disappearance  of  the  nor- 
mal contractility.  This  takes  place  early  in  certain  muscles,  so  that  in 
the  course  of  a  few  days  they  may  be  found  to  respond  faintly  or  not  at 
all  to  faradic  stimulation.  While,  however,  the  muscles  have  ceased  to  re-  < 
act  to  the  strong  faradic  current,  they  will  still  respond  to  slow  interrup- 
tions of  the  constant  ciuTcnt.  When  contractions  are  obtained  by  this 
means  in  a  muscle  which  has  lost  all  faradic  contractility  the  phenome- 
non is  called  "reaction  of  degeneration."  It  implies  that  the  muscle  for 
the  time  is  physiologically  cut  off  from  the  influence  of  the  spinal  cord. 
Besides  this,  early  signs  are  noticed  that  the  nutrition  of  the  limb  is  no 
longer  efficiently  maintained.  The  part  is  cold  and  often  looks  purple ; 
the  pulse  is  smaller ;  the  fat  becomes  absorbed ;  the  muscles  waste  ;  the 
ligaments  of  the  joints  are  relaxed  and  there  is  even  a  slackening  of  growth 
in  the  bone.  These  trophic  changes  are  usually  marked,  and  generally 
continue  after  apparent  restoration  of  power  in  the  affected  limb. 

The  paralysis  is  at  first  comjDlete  and  much  more  extensive  than  it 
afterwards  becomes.  After  some  weeks,  or  perhaps  months,  a  partial  re- 
covery takes  place  in  the  muscles  whose  faradic  contractility  had  not  been 
entirely  destroyed.  Sometimes  this  restitution  of  motor  powder  is  perfect, 
and,  except  for  the  impaired  nutrition  in  the  affected  limb,  the  child  may 
seem  to  be  well.  More  usually,  however,  certain  muscles,  or  groups  of 
muscles,  still  continue  disabled  ;  and  when  the  paralysis  has  thus  limited 
itself,  the  parts  which  remain  crippled  are  in  most  cases  permanently  use- 
less. 

When  the  paralysis  is  at  first  extensive,  there  appears  to  be  no  definite 
rule  as  to  the  parts  which  are  afterwards  to  recover  their  power.  If  an 
arm  and  a  leg  are  both  affected,  the  one  limb  does  not  necessarily  recover 
sooner  or  more  completely  than  the  other.  The  only  indication  is  the  • 
persistence  of  contractility  in  the  palsied  muscles.  Each  muscle  should 
be  carefully  tested  by  the  faradic  current,  and  in  those  whose  contractility 
is  not  destroyed  we  may  hope  for  eventual  recovery.  Cases  have  been  re- 
corded— notably  by  Dr.  Kennedy — in  which  the  limbs  recovered  early  and 
completely  without  the  disease  leaving  any  trace  of  its  passage  ;  but  it  has 
been  doubted  if  in  such  instances  the  lesion  is  the  same  as  in  those  where 
recovery  is  slow  and  more  or  less  imperfect. 

believes  that  facial  paralysis  occurs  so  seldom  because  the  acute  affection  invading  the 
bulb  is  not  likely  to  spare  the  nuclei  of  nerves  essential  to  life,  for  if  it  attacked  the 
nuclei  of  the  vagus  sudden  death  would  be  the  conseqiience.  He  suggests  that  cases 
of  sudden  or  rapid  death  in  young  children  may  be  sometimes  due  to  the  disease  strik- 
ing the  medulla  oblongata  with  the  same  suddenness  with  which  it  usually  attacks  the 
anterior  gray  matter  of  the  spinal  cord. 


INFANTILE  PAEALYSIS — SYMPTOMS.  375 

Iir  course  of  time  changes  take  place  in  the  muscles  which  remain  per- 
manently paralysed  after  the  general  restoration  of  power.  This  stage  of  the 
disease  is  called  the  period  of  atrophy  ;  for  the  affected  muscles  waste,  and 
at  the  same  time  the  slackening  of  growth  in  the  bone  becomes  a  notice- 
able feature  in  the  case.  This  arrest  of  development  in  the  affected  Umb 
has  been  already  referred  to.  It  is  a  variable  phenomenon  and  is  not  al- 
ways present.  When  it  occurs,  it  does  not  appear  to  be  proportioned  to 
the  severity  of  the  disease  as  to  muscular  wasting  and  paralysis  ;  but  may 
be  present  in  a  mild  case,  and  absent,  or  nearly  so,  in  a  severe  one.  Ac- 
cording to  Volkmann,  it  has  been  seen  incases  of  the  most  transient  infan- 
tile paralysis  where  the  muscles  quickly  recovered  their  power,  and  atrophy 
of  special  muscles  was  not  noticed.  As  the  growth  and  development  of 
the  unaffected  limbs  proceed  in  the  normal  manner,  the  difference  between 
the  two  sides  is  often  very  evident. 

The  wasting  of  the  muscles  permanently  paralysed  sometimes  begins 
eai'ly,  and,  according  to  Duchenne,  may  be  evident  at  the  end  of  a  month. 
As  a  rule  the  permanent  paralysis  is  not  widely  diffused.  It  is  not  com- 
mon to  find  a  whole  hmb  shrunken  and  useless,  although  even  this  mis- 
fortune may  occur.  Usually  it  is  a  group  of  muscles,  or  even  a  single 
one,  which  is  thus  disabled  ;  and  in  practice  certain  parts  more  than  others 
are  found  to  undergo  the  atrophic  change.  In  the  leg  the  common  exten- 
sor of  the  toes,  the  peronei  longus  and  brevis,  the  tibialis  anticus,  and 
sometimes  the  gastrocnemius  may  become  atrophied  ;  in  the  thigh,  parts 
of  the  triceps  extensor ;  of  the  muscles  attached  to  the  upper  extremity, 
the  deltoid,  the  serratus  magnus,  and  some  of  the  muscles  of  the  forearm. 

One  of  the  most  important  and  characteristic  results  of  the  disease  con- 
sists in  the  paralytic  cov  tractions  which  almost  invariably  occur  when  mus- 
cles are  permanently 'disabled,  and  constitute  various  kinds  of  deformity. 
They  are  especially  common  in  the  feet,  and  are  the  principal  cause  of  the 
different  forms  of  clubfoot  Avhich  develope  in  the  child  after  birth.  The 
contractions  occur  not  in  the  paralysed  muscles,  as  a  rule,  but  in  those 
which  still  retain  their  contractile  power.  They  begin  early,  and  tend  to 
increase  as  time  goes  on.  This  contraction  of  unaffected  muscles,  or  of 
muscles  only  partially  affected,  was  attributed  formerly  to  the  influence  of 
the  so-called  "  muscular  tonus."  It  was  supposed  that  a  constant  stimulus 
proceeded  from  the  spinal  cord,  and  kept  all  healthy  muscles  in  a  state  of 
persistent  slight  contraction.  In  the  normal  condition,  it  was  said,  oppo- 
site muscles  neutralise  each  other  ;  but  if  the  muscles  become  paralysed  on 
one  side,  so  that  the  contracting  power  on  that  side  is  aboHshed,  the  limb 
is  drawn  to  the  affected  side  by  the  action  of  the  "tonus"  in  the  unaffected 
muscles.  This  theoiy  was  combated  by  Werner,  who  maintained  that  the 
contraction  could  be  explained  without  recourse  to  the  imaginary  tonus. 
He  asserted  that  when  one  set  of  muscles  is  paralysed,  there  is  no  deform- 
ity until  the  opposite  set  of  muscles  is  put  into  action.  The  limb  is  then 
drawn  to  that  side  and  cannot  be  replaced  by  the  paralysed  antagonistic 
muscles.  It  therefore  remains  in  its  new  position  until  replaced,  or  until 
it  falls  back  again  by  its  own  weight.  Consequently,  it  must  happen  that 
the  limb  is  often  and  long  in  one  position,  for  the  muscles  once  contracted 
remain  so  because  the  antagonistic  muscles  can  no  longer  act.  After  a 
time  they  lose  the  power  to  relax,  and  a  permanent  contraction  becomes 
gradually  established. 

But  even  this  theory  does  not  account  for  the  whole  of  the  facts,  for, 
as  was  pointed  out  by  C.  Hiiter,  it  is  not  always  the  muscles  anatomically 
opposed  to  the  paralysed  groups  which  undergo  contraction  ;  and  indeed 


376  DISEASE  IlSr   CHILDEElSr. 

the  deviation  sometimes  occurs  in  the  direction  of  the  paralysed  side. 
The  real  cause  of  the  deformities  of  the  foot  appears  from  the  researches 
of  Hiiter,  Volkmann,  and  others,  to  be  only  partially  the  unopposed  action 
of  healthy  muscles  and  inability  to  antagonise  theu"  contractions.  Far 
more  imjportant  agents  are  the  weight  of  the  affected  part  itself  and  the 
greater  jDressure  thrown  upon  it  when  in  use.  For  instance,  the  common- 
est deformity  of  the  foot  is  the  talipes  equino-varus  ;  but  this  is  exactly 
the  position  in  which  the  foot  will  fall  when  the  ankle-joint  is  not  acted 
uj)ou  by  its  muscles.  If  a  child  be  made  to  sit  upon  the  edge  of  a  table, 
with  his  legs  hanging  down,  the  foot  instantly  falls  into  the  equino-varas 
position.  In  paralysis  of  the  Umb,  if  the  chUd  has  not  walked,  this  is  the 
form  the  deformity  invariably  takes.  The  foot  assumes  this  position,  and 
the  shortened  muscles  in  time  become  permanently  contracted.  The  ar- 
rest of  growth  in  the  bone,  which  is  generally  present,  promotes  the  for- 
mation of  this  deformity,  for  the  affected  leg  being  shorter  than  the  other, 
the  child  has  to  point  the  toes  in  order  to  reach  the  floor.  If  the  j)aralysis 
occur  in  a  child  who  has  ah'eady  learned  to  walk,  the  flat  foot  (talijDes  val- 
gus) is  the  usual  form  of  distortion,  and  is,  according  to  Volkmann,  irre- 
spective of  the  actual  muscles  paralysed.  When  the  jDatient  brings  his 
weight  to  bear  through  the  leg  upon  the  sole  placed  flat  on  the  ground, 
the  foot,  being  no  longer  braced  up  by  the  paralysed  muscles,  cui'ves  out- 
wards until  checked  by  the  ligaments.  By  repetition  of  this  action  the 
ligaments  stretch,  and  the  bones  on  the  compressed  side  are  interfered 
with  in  their  growth.  The  tahjjes  valgus  thus  formed  is  less  perfect  than 
the  same  deformity  produced  by  over-exercise  and  fatigue  in  a  child  with 
unparalysed  muscles,  for  during  rest  the  foot  is  brought  again  by  gravita- 
tion into  the  equino-varus  position.  The  shortened  muscles  are  therefore 
again  drawn  out,  and  their  contraction  is  less  complete,  so  that  the  joint  is 
comj)aratively  loose. 

When  the  muscles  of  the  thigh  are  permanently  weakened,  there  is  no 
contraction  about  the  knee  unless  the  child  attempt  to  aid  himself  by  the 
use  of  crutches.  Children  in  whom  there  is  partial  paralysis  of  the  quad- 
riceps femoris  walk,  says  Volkmann,  exactly  like  a  person  who  wears  an 
artificial  leg.  To  get  such  a  leg  to  support  the  weight  of  the  body  with- 
out bending  the  knee,  the  weight  must  be  thrown  in  front  of  and  not  be- 
hind the  joint.  Every  time  that  the  body  rests  upon  the  weakened  limb,  the 
weight  is  thrown  forwards,  so  that  the  knee  is  in  a  state  of  complete  exten- 
sion, and  the  posterior  hgaments  are  put  upon  the  stretch.  These  after  a  time 
relax,  and  the  knee  is  over-extended  so  as  to  produce  a  genu  recurvatum. 

In  the  arm,  the  elbow-joint  is  little  affected.  It  remains  quite  free,  and 
no  contractions  occur  unless  the  arm  is  kept  permanently  in  the  bent  posi-' 
tion,  as  when  worn  constantly  in  a  sling.  When  the  paralysis  is  so  marked 
that  the  hand  is  useless,  the  power  of  supination  of  the  arm  is  soon  lost, 
for  the  child,  having  no  occasion  for  the  movement,  soon  ceases  to  employ 
it.  The  wrist  becomes  slightly  flexed,  and  the  fingers,  completely  clenched 
upon  the  palm,  undergo  contraction  in  that  position.  This  is  the  position 
the  fingers  assume  when  left  to  themselves  ;  and  if  the  flexors  are  not  used, 
or  are  not  passively  stretched,  they  become  contracted.  The  shoulder  is 
flattened,  and  if  the  muscles  proceeding  from  the  thorax  to  the  arm  are  ex- 
tremely weakened,  the  capsule  is  pulled  upon  by  the  dead  weight  of  the 
arm  and  becomes  permanently  stretched,  so  that  a  distinct  interval  is  felt 
between  the  head  of  the  bone  and  the  socket.  In  this  case  the  affected 
arm,  by  raeasurement  from  the  acromion,  may  seem  longer  than  the  sound 
one. 


INFANTILE   PAKALYSIS — DIAGNOSIS — PEOGNOSIS.  377 

From  what  lias  gone  before  it  will  be  noticed  tliat  cases  of  infantile 
spinal  paralysis  fall  naturally  into  two  classes  :  those  in  which  complete 
recovery  takes  place  in  all  the  muscles  affected,  after  the  lapse  of  weeks  or 
months  ;  and  those  in  which  power  is  completely  restored  in  some  muscles, 
while  others  remain  permanently  useless,  and  the  disease  ends  in  atrophy 
and  deformity.  In  the  muscles  in  which  the  paralysis  is  likely  to  be  last- 
ing, faradic  contractility  disajDpears  at  a  very  early  date — usually  before  the 
end  of  the  first  week,  or  in  the  course  of  the  second.  According  to  the 
elder  Duchenne,  muscles  which  retain  some  degree  of  faradic  contractility 
on  the  seventh  or  eighth  day  may  be  expected  to  recover  their  power,  and 
this  the  more  rapidly  the  less  their  faradic  irritabihty  has  been  weakened. 

Diagnosis. — In  a  case  which  is  seen  at  an  early  period  of  the  disease 
the  symptoms  are  so  characteristic  that  it  is  difficult  to  mistake  this  form 
of  illness  for  any  other  lesion  of  the  nervous  system.  But  every  case  of 
paralysis  with  atrophy  is  not  a  case  of  infantile  spinal  paralysis.  To  iden- 
tify the  disease  with  accuracy  we  must  require  all  the  essential  j)henomena 
of  the  affection,  viz.,  complete  motor  paralysis  without  alteration  of  sensibil- 
ity or  pain  in  the  back  or  elsewhere  ;  rapid  loss  of  faradic  excitability  ;  a 
normal  temperature  ;  absence  of  paralysis  of  the  face  or  of  the  sphincters  ; 
complete  flaccidity  of  the  limb,  without  stiffness  or  contraction  of  the 
joints  ;  marked  coldness  of  the  affected  parts,  and  no  tendency  to  the  for- 
mation of  sores  upon  the  skin. 

In  acute  generalised  myelitis,  where  the  whole  of  the  gray  matter  is  in- 
volved and  a  large  part  of  the  white  columns,  there  is  lessened  cutaneous 
sensibility  ;  there  is  paralysis  of  the  sphincters,  so  that  the  child  can  no 
longer  control  the  bladder  or  the  bowel ;  there  is  an  increase  of  reflex  ex- 
citability ;  sores  form  readily  on  the  parts  exposed  to  pressure  ;  the  urine 
is  alkaline,  purulent,  and  offensive,  and,  as  a  rule,  atrophy  in  the  affected 
muscles  does  not  occui\ 

Haemorrhage  into  the  cord  produces  a  sudden  paralysis,  w^hich  is  fol- 
lowed by  atrophy  of  the  affected  muscles  and  loss  of  reflex  excitability ; 
but  here  also  there  is  diminution  of  cutaneous  sensibility,  the  sphinc- 
ters are  paralysed,  and  bed-sores  form  early. 

Paralysis  of  cerebral  origin  may  be  distinguished  by  the  affection  of 
the  cerebral  nerves,  such  as  squinting,  facial  paralysis,  etc.  ;  by  the 
palsy  being  accompanied  by  tension  of  the  muscles  and  spasmodic  contract- 
ures ;  by  the  preservation  of  electiical  irritability ;  by  the  stil&ess  and 
extension  of  the  joints ;  by  increased  excitability  of  tendons,  and  by  the 
absence  of  atrophy. 

In  spasmodic  spinal  paralysis  the  loss  of  power  is  incomplete,  and  occurs 
slowly  and  insidiously  ;  muscular  tension  and  contractions  are  present ; 
there  is  increased  irritability  of  the  tendons,  and  the  affected  muscles  do 
not  atrophy. 

The  course  of  infantile  paralysis  is  also  very  characteristic.  The  rapid 
restoration  of  power  in  the  larger  number  of  muscles  affected  and  the 
complete  paralysis  of  others  is  very  peculiar  ;  also  the  arrest  of  growth, 
which  embraces  the  whole  of  the  region  first  affected,  is  a  very  striking- 
phenomenon.  At  a  later  period,  when  contractions  occur  ia  the  limb, 
the  resulting  deformity  may  be  distinguished  from  congenital  distortion 
by  the  very  partial  atrophy  of  muscles,  the  striking  looseness  of  the  liga- 
ments of  the  joint,  and  the  permanent  coldness  of  the  part. 

Prognosis. — As  infantile  paralysis  is  not  a  fatal  form  of  illness,  our  chief 
anxiety  must  be  to  estimate  the  chances  of  complete  recovery  in  the  par- 
alysed muscles.     For  our  own  comfort  and  that  of  the  friends  we  may  re- 


378  DISEASE  IN   CHILDEEN". 

member  that  complete  recovery,  or  at  any  rate  vast  improvement,  is  the 
rule  and  not  the  exception.  Careful  testing  with  the  faradic  current  will 
give  us  very  accurate  means  of  determining  in  which  muscles  speedy  res- 
toration of  power  may  be  anticipated,  and  in  which  of  them  persistent 
paralysis  is  to  be  feared.  The  muscles  which  have  lost  all  physiological 
connection  with  the  spinal  cord  no  longer  respond  to  the  induced  current, 
while  they  react  to  slow  interruptions  of  the  constant  current  (reaction  of 
degeneration).  This  change  takes  place  very  rapidly.  Faradic  irritability 
is  enfeebled  as  early  as  the  third  or  fifth  clay,  and  is  lost  by  the  seventh  or 
eighth. 

In  testing  the  irritabiHty  of  the  muscles  at  this  period  a  weak  current 
should  be  used — one  just  sufficient  to  cause  contraction  in  healthy  mus- 
cles. Every  muscle  which  does  not  react  to  the  faradic  current  after  the 
lapse  of  a  fortnight  from  the  beginning  of  the  illness  is  likely  to  be  per- 
manently disabled.  Still,  according  to  G.  Sigerson,  muscles  which  have 
long  ceased  to  contract  may  sometimes  regain  their  faradic  contractility 
and  recover  their  power  more  or  less  completely.  On  the  other  hand,  in 
the  muscles  which  retain  some  amount  of  faradic  mitability,  however 
faintly  they  may  react  to  the  current,  return  of  power  may  be  confidently 
predicted.  Even  when  recovery  from  the  paralysis  is  complete,  the  child 
is  still  liable  to  some  arrest  of  growth  in  the  affected  limb  ;  and  it  is  well 
to  warn  the  friends  of  the  patient  of  this  possible  consequence  of  his  ill- 
ness. 

Treatment. — If  we  have  the  opportunity  of  seeing  the  child  immediately 
after  the  occurrence  of  the  paralysis,  we  should  keep  him  perfectly  quiet 
in  bed,  clear  out  his  bowels  with  a  brisk  aperient,  and  employ  counter- 
irritation  to  the  region  of  the  spine.  By  the  repeated  application  of  mus- 
tard poultices,  first  to  one  part,  then  to  another,  of  the  spine,  a  derivative 
action  may  be  kept  up  as  long  as  the  skin  will  bear  it.  During  the  early 
days  of  the  disease  it  is  weU  to  insist  upon  a  prone  position,  varied  occa- 
sionally by  laying  the  patient  on  his  side.  The  dorsal  position,  which 
favours  congestion  of  the  vessels  within  the  spinal  canal,  should,  if  possi- 
ble, be  avoided.  The  child  should  be  put  upon  a  diet  of  milk  and  broth, 
and  care  should  be  taken  that  his  bowels  act  regularly  once  a  day.  While 
there  is  any  fever  Dr.  Althaus  recommends  a  daily  subcutaneous  injection 
of  a  solution  of  Bonj  can's  ergo  tine — a  quarter  of  a  grain  for  a  child  of 
twelve  months.  At  first  no  local  treatment  is  admissible  to  the  paralysed 
muscles  ;  and  the  faradic  current  should  be  used  only  for  diagnostic  pur- 
poses and  not  as  a  therapeutic  agent.  But  immediately  any  recovery  of 
power  begins  to  be  noticed,  we  should  employ  the  faradic  current  daily,  so 
as  to  aid  the  restoration  of  the  affected  muscles.  If  there  is  at  first  no  re- 
sponse to  the  induced  current,  the  continuous  current,  with  slow  inter- 
ruptions may  be  employed.  It  is  advisable  to  use  a  current  of  sufficient 
strength  to  cause  a  visible  contraction  of  the  muscles.  .  This,  however,  is 
often  impossible  with  children.  Even  a  weak  application  may  cause  such 
agitation  and  alarm  that  its  employment  has  to  be  discontinued.  We 
should  not  in  any  case  use  a  strong  current  at  first.  Probably  a  weak 
current,  in  its  influence  upon  the  nutrition  of  the  muscle,  is  preferable  to 
none  at  aU.  Dr.  Gowers  recommends  that  in  the  beginning  such  a  strength 
should  be  employed  as  the  child  will  bear  without  much  emotional  disturb- 
ance, and  if  care  be  taken  not  to  alarm  the  child  at  the  first,  a  current  of  con- 
siderable strength  can  be  perhajps  made  use  of  afterwards. 

Besides  electricity  other  means  should  be  used.  The  paralysed  limb 
must  be  kept  warm  with  cotton  wadding.     This  is  a  matter  the  impor- 


INFANTILE   PARALYSIS — TREATMENT.  379 

tance  of  which  lias  been  very  properly  insisted  upon  by  Dr.  R.  J.  Lee,  If 
the  affected  parts  are  very  cold,  they  may  be  rubbed  several  times  a  day 
before  the  fire  ;  and  hot  applications  of  any  kind — bags  of  hot  salt,  bran, 
hot  flannel,  etc.,  may  be  kept  in  contact  with  the  limb  to  maintain  its  tem- 
perature. Great  assistance  will  also  be  derived  from  vigorous  shampooing. 
It  is  advisable  to  order  stimulating  liniments  for  this  purpose,  as  frictions 
are  always  employed  with  more  energy  if  something  is  given  "to  be 
rubbed  into  the  skin."  The  child  should  be  also  encouraged  to  use  the 
weakened  limb  as  much  as  possible  ;  and  Volkmann  insists  strongly  upon 
the  worse  than  uselessness  in  these  cases  of  crutches  or  other  forms  of 
mechanical  support. 

It  is  usual  to  give  strychnia  to  these  patients,  either  internally  or  by 
subcutaneous  injection.  The  remedy  has  probably  little  influence  in  re- 
storing power  to  the  disabled  muscles,  but  as  a  general  tonic  its  use  may 
be  not  without  value  during  the  stage  of  recovery.  It  may  be  combined 
with  iron  and  quinine. 

In  most  cases  of  infantile  paralysis,  when  recovery  does  not  take  place 
within  the  first  two  months,  the  course  of  the  disease  is  long  and  tedious, 
and  improvement  goes  on  but  slowly.  Still,  our  efforts  are  eventually  re- 
warded by  a  striking  return  of  power  even  in  cases  which  at  first  had  ap- 
peared almost  hopeless. 

The  cure  of  the  deformities  resulting  from  atrophy  and  contraction  of 
muscle  come  under  the  department  of  the  surgeon. 


CHAPTEE  XVII. 

SPASMODIC   SPINAL   PARALYSIS. 

Spasmodic  spinal  paralysis,  sometimes  called  spastic  paraplegia,  appears 
from  the  researches  of  Charcot  and  of  Erb  to  be  due  to  a  sclerosis  of  the 
lateral  columns  of  the  cord.  The  disease,  which  consists  in  a  gradually 
advancing  weakness  or  paralysis  of  the  limbs — generally  the  legs — is  some- 
times seen  in  children  and  even  in  young  babies  ;  indeed  in  many  cases  it  ap- 
pears to  be  congenital.  Like  infantile  spinal  paralysis  the  lesion  is  accom- 
panied by  no  distui'bance  of  the  cerebral  functions,  no  affection  of  sensation, 
and  no  loss  of  control  over  the  bladder  and  rectum  ;  but,  unlike  infantile 
l^aralysis,  the  affected  muscles  seldom  waste,  there  is  excessive  rigidity  of 
the  joints,  and  the  tendinous  reflexes,  instead  of  being  abolished,  are  in- 
creased in  activity. 

Causation. — The  lesion  may  develop  itseK  in  the  earliest  childhood. 
Its  causes  are  unknown.  Seligmueller  has  recorded  an  instance  in  which 
four  children  of  the  same  family  suffered  from  a  form  of  the  affection. 

Morbid  Anatomy. — No  cases  of  death  from  this  disease  have  been  no- 
ticed in  children  ;  but  in  adults  the  symptoms  have  been  connected  by 
Charcot  with  degeneration  of  the  lateral  columns  of  the  cord.  On  section 
of  the  cord  the  gray  degeneration  is  seen  to  be  symmetrical  and  to  occupy 
the  lateral  columns  on  each  side  of  the  cord.  The  diseased  region,  as 
seen  on  the  surface  of  the  section,  is  triangular  in  shape,  and  reaches  in- 
wards to  the  anterior  gray  cornua,  outwards  to  the  pia  mater  ;  in  front  it 
passes  gradually  into  the  healthy  substance  of  the  columns.  The  degen- 
eration is  not  in  patches,  but  appears  to  be  diffused  over  the  greater  por- 
tion of  the  length  of  the  cord,  and  may  reach  up  to  the  medulla  or  even 
beyond  it.  In  some  spots  the  j)rocess  is  more  intense  than  it  is  in  others. 
On  microscopical  examination  of  the  degenerated  portions,  the  neuroglia 
is  found  to  be  thickened,  the  nerve  fibres  to  be  degenerated  and  wasted, 
and  the  ganglion  cells  to  be  cloudy  and  swollen,  or  atrophied,  pigmented, 
and  finally  almost  destroyed. 

Syvvptoms. — Whatever  may  be  the  age  of  the  child  when  he  first  comes 
under  observation,  we  shall  generally  find  that  the  symptoms  date  back  to 
the  period  of  infancy,  and  that  they  were  first  noticed  only  a  few  weeks  or 
months  after  birth.  On  questioning  the  mother  we  commonly  hear  that 
when  quite  a  baby  the  child's  legs  were  stiff",  and  that  on  this  account 
washing  and  dressing  him  was  a  troublesome  matter  ;  that  although  able 
to  move  his  legs  when  lying  down,  he  could  never  stand,  and  that  any  at- 
tempt to  do  so  increased  the  stiffness.  If  he  did  succeed  in  walking  at  an 
age  long  after  that  at  which  a  healthy  child  can  run  alone,  he  was  never 
firm  on  his  legs,  and  soon  became  weaker  and  tumbled  about.  Then  ihe 
power  deserted  him  altogether,  and  when  placed  on  his  feet  his  legs  be- 
came- stiff  and  crossed,  the  toes  touching  the  ground  but  the  heels  being 
raised.     As  there  is  no  fever,  pain,  or  evident  impairment  of  nutrition,  and 


SPASMODIC   SPINAL   PAKALYSIS— SYMPTOMS.  381 

as  in  many  cases  the  mental  development  is  satisfactory,  the  weakness  is 
looked  upon  as  a  personal  peculiarity  which  the  child  will  "grow  out  of," 
and  he  seldom  comes  under  observation  until  the  disease  is  fully  devel- 
oped. 

In  a  child  so  afflicted  two  phenomena  are  at  once  noticed :  there  is 
weakness  of  the  lower  limbs,  and  the  joints  are  stiff,  and  become  stiffer 
when  handled. 

On  examination  we  find  that  the  legs  are  moved  awkwardly  and  with 
difficulty.  As  the  child  lies  in  his  cot  the  limbs  are  extended  and  only 
slightly  flexed,  and  the  patient  may  have  some  power  of  bending  his  joints, 
although  some  are  moved  with  greater  facility  than  others.  The  muscles 
feel  rigid  to  the  touch,  and  when  the  joints  are  forcibly  flexed — which  can 
be  done  without  inflicting  pain  upon  the  child — they  straighten  again  ab- 
ruptly, as  if  moved  by  a  spring.  Handling  the  limbs  increases  the  rigidity 
of  the  joints,  and  often  the  mere  approach  of  the  physician  appears  to  have 
the  same  effect.  Movement,  whether  active  or  passive,  produces  no  tremors 
in  the  affected  limbs.     It  only  increases  the  rigidity  of  the  muscles. 

When  the  child  is  held  under  the  arms,  so  as  to  feel  the  ground  with 
his  feet,  directly  he  attempts  to  walk  the  thighs  are  closely  pressed  together, 
the  knees  are  slightly  bent,  the  feet  are  inverted,  and  the  ankles  extended 
so  that  only  the  points  of  the  toes  touch  the  floor  ;  the  legs  become  rigid 
and  soon  cross  one  over  the  other.  In  bad  cases  the  heels  are  not  brought 
into  contact  with  the  ground  at  aU.  Sometimes  the  child,  although  he 
cannot  walk,  is  able  to  stand,  supporting  himself  against  some  object.  The 
rigidities  appear  to  contribute  to  his  helplessness  as  much  as  the  motor 
weakness  ;  and  sometimes  the  attempt  at  voluntary  movement,  conflicting 
with  the  stiffness  of  the  muscles,  results  in  a  sort  of  chorea. 

The  back  is  often  very  weak,  and  the  muscles  of  the  abdomen  may  be- 
come hard  when  the  skin  is  irritated.  Control  over  the  sphincters  is  not 
interfered  with  ;  there  is  no  paralysis  of  the  face,  nor  any  tendency  to  the 
formation  of  sores  or  sloughs  upon  the  parts  exposed  to  pressure.  The 
degree  of  intelligence  varies  in  different  cases.  Often  the  child  seems  as 
quick  as  others  of  his  age,  but  sometimes  he  is  dull  and  stupid.  Articula- 
tion may  be  affected,  but,  as  a  rule,  the  patients  speak  readily  and  clearly. 

Occasionally  the  arms  are  affected.  In  a  case  reported  by  Dr.  Oee — 
a  little  girl,  eight  years  old,  in  whom  the  paralysis  had  existed  certainly 
from  the  age  of  twelve  months,  perhaps  from  an  earlier  period — the  arms 
as  weU  as  the  legs  became  stiff'  when  the  giii  was  noticed.  The  arms  were 
rotated  outwards  ;  the  elbows  were  strongly  extended  and  the  wrists  pro- 
nated  ;  the  hands  were  also  extended  strongly  and  thrown  back  at  the 
wrist ;  the  fingers  were  flexed.  The  child  could  move  the  opposing  mus- 
cles, but  with  difficulty,  and  after  movement  the  arms  soon  returned  into 
the  position  described.  The  left  arm  was  more  affected  than  the  right. 
Dr.  Gee  has  described  eight  cases  of  this  interesting  malady,  of  which  the 
first  was  observed  before  the  publications  of  Erb  and  Charcot  had  attracted 
general  attention  to  the  disease. 

The  constant  rigidity  of  the  muscles  affected  is  not  accompanied,  as  a  . 
rule,  by  any  wasting,  although  in  exceptional  cases,  when  the  disease  is  of 
long  standing,  one  or  more  (not  all)  of  the  implicated  muscles  may  show 
some  signs  of  atrophy.  The  rigidity  is  a  permanent  phenomenon,  persist- 
ing during  sleep,  and  only  disappearing  temporarily  when  the  child  is  placed 
under  the  complete  influence  of  chloroform.  The  tendinous  reflexes  are 
more  active  than  in  the  normal  state,  and  the  response  to  faradism  is  rapid 
and  energetic.     Sensation  is  unimpaired. 


382  DISEASE  IN  CHILDREN. 

In  many  cases  the  actual  amount  of  weakening  of  tlie  muscles  appears 
to  be  slight.  The  impediment  to  walking  seems  to  be  more  the  resiilt  of 
rigidities  and  contractions  of  muscles,  which  prevent  the  foot  and  limb  from 
being  placed  in  a  fitting  position  to  support  the  weight  of  the  body  and 
frustrate  the  voluntary  impulse,  rather  than  of  any  actual  paralysis.  From 
observations  made  upon  the  adult  sufferer,  contractions  are  found  to  occur 
as  a  later  phenomenon,  the  muscles  being  merely  rigid  at  first  without  any 
shortening  in  their  length.  When  the  contractions  come  on  the  paresis 
becomes  more  noticeable.  Eventually  it  may  amount  to  complete  loss  of 
voluntary  motor  power.  This  is,  however,  generaUy  of  unequal  intensity 
in  different  regions,  being  well  develojjed  in  certain  groups  of  muscles,  im- 
perfect in  others.  Usually  the  disease  is  more  advanced  in  one  of  the 
limbs  than  it  is  in  its  fellow. 

If  a  child,  the  subject  of  this  disease,  be  able  to  walk,  his  gait  is  very 
peculiar.  The  patient  behaves  as  if  giddy,  and  sways  from  side  to  side. 
His  Hmbs  are  widely  separated,  and  he  moves  each  leg  awkwardly  forward, 
often  shding  it  along  the  ground.  The  tendency  appears  to  be  to  point 
the  foot  so  that  the  heel  is  not  in  full  contact  with  the  floor.  Conse- 
quently the  toes  are  apt  to  catch  at  any  unevenness  of  the  ground,  and  the 
child  would  fall  on  his  face  if  not  supported. 

As  the  disease  advances  all  the  symptoms  become  intensified.  The 
rigidities,  the  contractions,  the  paresis,  and  the  reflex  irritability,  all  be- 
come increased.  The  lesion  does  not  appear  to  be  fatal  to  life.  Of  its 
later  stages  Httle  is  known,  for  after  a  certain  degree  of  intensity  is  reached, 
and  the  patient  has  been  rendered  quite  helpless,  the  disease  seems  to 
undergo  no  further  change. 

Diagnosis. — The  essential  features  of  the  disease  are  a  slowly  growing 
paralysis  of  the  lower  extremities,  without  wasting,  but  accompanied  by 
excessive  spasmodic  rigidity  of  muscle  and  increased  activity  of  the  tendi- 
nous reflexes.  The  disease  is  therefore  readily  distinguished  from  infan- 
tile spinal  paralysis,  in  which  wasting  and  arrest  of  growth  in  the  aflfected 
limb  are  the  rule  ;  the  joints,  far  from  being  rigid,  are  excessively  relaxed, 
and  the  tendinous  reflexes  are  abolished. 

General  acute  myelitis  resembles  the  spastic  disease  in  its  increase  of 
reflex  excitability  and  absence  of  atrophy,  but  differs  from  it  by  producing 
paralysis  of  the  sphincters,  diminishing  the  cutaneous  sensibility,  and  pro- 
moting the  formation  of  bed-sores.  Besides,  there  is  a  well-defined  hori- 
zontal limit  beyond  which  the  disease  does  not  pass,  and  there  is  no  ap- 
proach to  the  muscular  rigidity  which  is  such  a  characteristic  feature  of 
spasmodic  spinal  paralysis. 

In  paralysis  of  cerebral  origin  the  loss  of  power  is  accompanied  by  ten- 
sion of  muscle  and  spasmodic  contractions,  the  joints  are  stiff  and  ex- 
tended, the  muscles  do  not  atrophy  and  continue  to  respond  to  faradism, 
and  the  reflex  irritability  of  tendons  is  preserved.  But  in  such  a  case  there 
is  paralysis  of  cerebral  nerves,  the  loss  of  power  is  hemiplegic  in  distri- 
bution, the  rigidities  and  contractions  are  very  late  to  occur,  and  sensa- 
tion as  well  as  motion  is  affected. 

Prognosis. — The  life  of  the  patient  appears  to  be  in  no  danger  from  the 
illness,  but  at  the  same  time  his  chances  of  recovery  are  small.  Little  is 
known  as  to  the  course  of  the  disease  in  the  child,  but  none  of  Dr.  Gee's 
cases  were  influenced  by  treatment  in  the  slightest  degree. 

Treatment. — Erb  recommends  the  galvanic  current  applied  principally 
to  the  spine,  but  also  to  the  affected  limbs,  and  the  application  of  cold 
compresses.     Drugs  appear  to  have  but  slight  influence  on  the  disease. 


SPASMODIC   SPINAL   PAEALYSIS — TREATMENT.  383 

In  a  case  of  recovery  reported  by  Von  der  Velden — in  a  man  aged  twenty- 
seven — bromide  of  potassium,  belladonna,  and  morpliia  had  no  beneficial 
influence  ;  indeed,  the  latter  seemed  to  increase  the  number  and  intensity 
of  the  attacks.  Chloral,  however,  was  useful' in  moderating  the  spasmodic 
attacks  when  they  were  at  their  worst,  and  improvement  began  to  be  man- 
ifested while  the  patient  was  taking  the  double  salt  of  gold  and  sodium. 
In  Dr.  Gee's  cases  hemlock,  belladonna,  Calabar  bean,  and  strychnia — the 
two  last  hypodermically — were  used  in  turn,  but  without  the  slightest 
benefit. 


CHAPTER    XV  III. 

PSEUDO-HYPERTROPHIC   PARALYSIS. 

This  singular  form  of  paralysis,  in  which  extreme  feebleness  of  the  muscles 
is  combined  with  an  appearance  of  extraordinary  development  and  vigour, 
was  first  studied  and  described  by  Duchenne,  of  Boulogne.  Almost  at  the 
same  time,  however.  Dr.  Edward  Meryon,  in  England,  had  pubHshed  some 
interesting  particulars  of  four  boys  in  the  same  family  who  were  all 
affected  with  what  appears  to  have  been  hypertrophic  paralysis,  although 
the  author  at  the  time  was  of  opinion  that  the  disease  was  identical  vnth 
progressive  muscular  atrophy.  Many  cases  have  since  been  placed  upon 
record,  and  there  must  be  few  children's  hospitals  which  have  not  at 
one  time  or  another  had  an  example  of  the  disease  within  their  walls. 

Causation. — Of  the  etiology  of  the  infirmity  nothing  is  known.  It  is  in 
the  large  majority  of  cases  confined  to  the  male  sex:  In  Dr.  Meryon's 
first  series  of  cases,  above  referred  to,  all  the  boys  (four)  of  the  family  suf- 
fered from  it,  while  the  eight  girls  escaped.  This  fact  also  illustrates 
another  tendency  of  the  disease,  viz.,  its  proneness  to  attack  several  mem- 
bers of  a  family.  Two,  four,  and  more  children  of  the  same  parents  have 
been  known  to  be  affected,  and  Dr.  Meryon  has  referred  to  a  striking 
instance  in  which  eight  brothers  all  died  of  the  disease.  This  tendency  seems 
to  point  to  a  hereditary  element  in  the  etiology  of  the  infirmity.  In  investi- 
gating this  qiiestion  it  is  not  enough,  as  Dr.  Gowers  has  pointed  out,  to 
ascertain  merely  the  health  of  the  parents.  Females  are  rarely  affected  by 
it,  and  males,  the  subjects  of  the  disease,  usually  die  at  or  soon  after 
puberty.  Therefore  the  tendency  must  be  searched  for  amongst  the 
collateral  branches  of  the  family.  Such  evidence  is  generally  found  on  the 
side  of  the  mother,  and  instances  of  the  disease  in  some  members  of  her 
family  can  be  discovered  sufficiently  often  to  determine  positively  the  fre- 
quent existence  of  this  one-sided  inheritance. 

The  disease  appears  to  be  limited  to  childhood,  and,  indeed,  is  often 
congenital,  the  first  symptoms  manifesting  themselves  during  infancy  or 
shortly  after  that  period.     It  seldom  begins  after  the  sixth  year. 

Morbid  Anatomy. — No  morbid  changes  have  as  yet  been  discovered  in 
any  part  of  the  nervous  system  to  account  for  the  disease,  but  the  changes 
in  the  affected  muscles  themselves  are  sufiicient  to  explain  the  phenomena 
of  the  affliction,  and  especially  the  apparent  inconsistency  between  the 
unusual  size  of  the  muscles  and  their  remarkable  want  of  power. 

In  the  muscles  the  morbid  process  consists  in  an  overgrowth  of  the 
interstitial  connective  tissue  between  the  fibres.  The  nucleated  fibrous 
tissue  and  the  fat  cells  gradually  increase  in  quantity  and  compress  the 
muscular  fibres.  These  under  the  pressure  become  narrower,  and  their 
strisB  farther  apart,  although  still  distinct;  afterwards  the  striations  become 
indistinct,  and  the  fibres  dwindle  and  eventually  disappear,  leaving  the 


PSEUDO-HYPEETEOPHIC   PAEALYSIS — SYMPTOMS.  385 

empty  sarcolemma  sheath  running  by  the  side  of  the  fibrous  bundles  and 
prohferated  fat  cells. 

If  the  fat  is  greatly  increased  in  quantity,  the  muscles  on  section  may 
have  the  appearance  of  a  fatty  tumour  in  which  no  sign  of  muscular  red- 
ness is  visible  to  the  naked  eye.  Under  the  microscope  the  fibres  are  seen 
to  be  separated  by  fat  cells,  but  it  is  not  common  to  find  fatty  degeneration 
of  the  muscular  fibres  themselves. 

Symptoms. — The  earher  symptoms  are  very  apt  to  escape  notice  as  they 
have  no  distinctive  character.  They  consist  merely  in  weakness  of  certain 
muscles,  usually  those  of  the  lower  limbs,  and  sometimes  of  the  back.  If 
the  disease  begins  in  early  infancy,  before  the  time  for  walking  has  arrived, 
the  child  is  noticed  to  be  heavy  to  Hft,  and  to  want  the  responsive 
"  spring  "  which  is  so  marked  a  feature  in  the  healthy  infant.  In  such  a 
case  it  is  late  before  he  acquires  the  power  of  walking.  If  he  has  been 
able  to  walk  before  the  disease  begins,  he  very  quickly  gets  tired,  and 
shows  a  curious  unsteadiness  when  on  his  legs.  He  can  be  thrown  off  his 
balance  by  a  slight  push,  and  when  on  the  ground  rises  again  with  difii- 
culty.  When  the  weakness  of  the  muscles  has  reached  a  certain  degree, 
the  child  is  forced  to  assume  a  characteristic  attitude.  In  standing  he 
separates  his  legs  widely,  and  throws  his  shoulders  backwards  so  as  to 
exaggerate  the  antero-posterior  curve  of  the  lumbar  spine.  Consequently 
his  bellj^  is  protruded,  and,  in  a  marked  case,  a  vertical  Hne  di'opped  from 
the  back  of  the  neck  falls  clear  of  the  buttocks.  This  attitude  is  the  con- 
sequence of  weakness  of  the  extensors  and  flexors  of  the  hip  and  the  exten- 
sors of  the  knee — the  muscles  which  maintain  the  body  upright  in  stand- 
ing. The  child,  feeling  these  to  be  insecure,  tries  by  separating  his  feet  to 
enlai'ge  his  base,  and  as,  owing  to  the  weakness  of  the  extensors  of  the  hip, 
the  pelvis  is  inclined  unnaturally  forwards,  he  throws  his  shoulders  back- 
wards so  as  to  keep  the  centre  of  gravity  in  the  normal  position.  As  he 
walks  he  still  continues  to  separate  his  feet  widely,  and  he  sways  his 
body  from  side  to  side  so  as  to  keep  the  centre  of  gravity  over  the  foot 
upon  which  the  weight  of  the  body  is  resting. 

After  a  certain  number  of  months,  or,  according  to  Duchenne,  a  year  has 
elapsed,  changes  can  be  noticed  in  the  muscles,  and  the  weakness  becomes 
more  marked.  The  calves  of  the  legs  become  enlarged,  so  as  to  give  the 
appearance  of  unusual  vigour,  and  generally  a  similar  hypertrophy  affects 
other  muscles  as  well.  The  gluteal  muscles,  the  muscles  of  the  thighs,, 
the  posterior  muscles  of  the  spine,  the  deltoids,  and  sometimes  almost  all 
the  muscles  of  the  trunk  and  Hmbs  may  share  in  this  enlargement.  If 
the  muscles  do  not  become  h;ypertrophied,  they  usually  waste,  and  this, 
diminution  in  size  of  some  muscles  renders  more  striking  the  extraordi- 
nary hypertrophy  which  affects  other  muscles  in  their  neighbourhood. 

As  the  weakness  of  the  muscles  goes  on  progressively  increasing,  the 
characteristic  attitude  and  gait  become  more  and  more  marked.  At  the 
same  time  any  sUght  extra  strain  put  upon  the  muscles  in  the  performance 
of  certain  acts  increases  the  difficulty  to  such  a  degree  that  the  child  is  re- 
duced to  some  very  curious  expedients  in  order  to  accomplish  them  suc- 
cessfully. Thus,  in  rising  from  a  chair,  he  endeavours  to  assist  the 
extension  of  the  knee-joint  by  placing  a  hand  on  each  femur  just  above 
the  knee.  By  this  means,  especially  if  at  the  same  time  he  bend  forwards, 
he  transfers  a  large  part  of  the  weight  from  the  extremity  (the  hip)  of  a 
lever  whose  fulcrum  is  at  the  knee  to  a  part  of  the  lever  close  to  the 
fulcrum  ;  or,  even,  if  the  body  is  bent  forwards  sufficiently  to  throw  the 
centre  of  gravity  in  front  of  the  knees,  actually  uses  the  weight  to  be 
25 


386  DISEASE   I]Sr   CHILD EETT. 

moved  as  a  motor  power  to  effect  tlie  straightening  of  the  knee-joint. 
Again,  in  extending  the  hip-joints  the  patient  begins  by  placing  his  hands, 
as  in  the  former  case,  just  above  the  knee,  and  then  moves  the  hands 
alternately  higher  and  higher  until  the  straight  position  is  arrived  at. 

For  some  time  the  muscles  retain  sirfficient  power  to  carry  the  patient 
at  a  moderate  pace  along  a  level  surface  ;  but  he  cannot  jump,  and  in 
mounting  the  stairs  he  is  forced  to  do  so  on  his  hands  and  knees.  If  told 
to  get  up  from  the  ground,  the  child  can  only  obey  by  going  thi'ough  a 
series  of  elaborate  manoeuvres,  all  calculated  to  reheve  or  assist  the 
weakened  muscles.  As  Dr.  Gowers  describes  the  process,  the  patient, 
being  on  all  fours,  keeps  his  hands  on  the  ground,  and  stretches  the  legs 
out  behind  him  far  apart.  Then,  still  keeping  the  body  suj^ported  chiefly 
by  the  hands,  he  manages  by  shuffling  backwards  on  the  toes  to  get  the 
knees  extended.  The  body  is  thus  supported  by  the  hands  and  feet  all 
placed  as  widely  apart  as  possible.  Next,  the  hands  are  alternately  moved 
backwards  along  the  ground  so  as  to  bring  the  larger  portion  of  the 
weight  of  the  trunk  over  the  legs.  Then,  one  hand  is  placed  on  the  knee, 
and  a  push  with  this,  and  with  the  other  stiU  on  the  ground,  is  sufficient 
to  enable  the  extensors  of  the  hip  to  bring  the  trunk  into  the  upright  po- 
sition. In  many  cases  the  child  cannot  rise  at  all  unless  near  to  some 
piece  of  f  urnitiu-e,  by  means  of  which  he  can  gradually  hoist  his  trunk  up- 
wards with  his  hands. 

As  the  paralysis  extends  the  patient  gets  more  and  more  helpless ;  and 
when  the  upper  limbs  become  affected,  as  usually  happens  after  a  few 
years  have  elapsed,  his  condition  is  very  distressing. 

The  affected  muscles  do  not  always  increase  in  size.  Sometimes  they 
waste,  and  the  hypertrophy  and  atrophy  are  irregularly  distributed.  Usu- 
ally many  more  muscles  are  wasted  than  are  enlarged.  The  hypertro- 
phy is  apt  to  affect  by  preference  certain  muscles.  The  muscles  of  the 
cafl,  the  vasti  of  the  thigh,  the  glutsei,  the  infra  spinati,  and  the  del- 
toids are  often  enlarged.  On  the  contrary,  the  muscles  on  the  front  of 
the  leg  are  more  usually  wasted,  and  wasting  is  also  more  common 
in  the  latissimus  dorsi  and  the  sterno-costal  portion  of  the  great  pectoral 
muscle.  In  the  arm  the  biceps  and  triceps  may  be  enlarged,  but  the 
muscles  of  the  forearm  are  rarely  affected.  Sometimes  the  temporals  and 
masseters  are  hypertroiDhied.  In  some  rare  cases  the  miiscles,  before  they 
begin  to  enlarge,  have  been  noticed  to  be  smaller  than  natural. 

This  form  of  paralysis  is  not  accompanied  by  any  general  fever,  but 
Dr.  Ord  has  noticed  a  higher  temperature  in  the  leg  where  the  muscles 
are  hypertrophied  than  in  the  corresponding  thigh.  This,  however,  is  not 
a  constant  phenomenon.  At  first  the  muscles  resj)ond  normally,  or  nearly 
so,  to  the  galvanic  current,  both  interrupted  and  continuous  ;  but  when 
greatly  wasted,  the  muscular  response  is  weak,  or  even  absent.  The  knee 
reflex  is  usually  notably  diminished.  Sensation,  however,  is  unimpaii'ed, 
and  there  is  perfect  control  over  the  bladder  and  sphincter. 

Towards  the  end  of  the  disease  contraction  and  shortening  may  occur 
in  certain  muscles — usually  in  those  the  opponents  of  which  are  exces- 
sively enfeebled.  This  is  a  phenomenon  which  is  seen  in  other  forms  of 
paralysis,  and  its  mechanism  is  discussed  elsewhere  (see  page  375).  There 
is,  however,  one  form  of  contraction  which  has  been  said  by  Duchenne  to 
be  a  constant  symptom  of  pseudo-hypertrophic  paralysis.  This  is  seldom 
noticed  before  the  end  of  the  sixth  year.  It  takes  place  at  an  earlier 
period  than  the  ordinaiy  paralytic  contractions,  and  occui'S  as  a  conse- 
quence of  shortening  in  the  length  of  the  diseased  gastrocnemii.     These 


PSEUDO-IIYPEETEOPHTC   PARALYSIS — DIAGNOSIS.  387 

muscles  draw  up  the  heel  so  that  the  patient  cannot  press  this  part  of  his 
foot  to  the  ground,  and  as  the  contraction  increases  a  tahpes  equinus 
is  developed.  The  deformity  is  usually  symmetrical.  When  combined 
with  the  muscular  weakness  it  makes  walking  very  difficult.  Consequently 
there  is  nothing  to  oppose  further  contraction,  and  the  exte;asion  of  the 
ankle  soon  becomes  extreme. 

The  disease  may  be  associated  with  idiocy  and  mental  feebleness,  as 
ajDpears  from  some  cases  published  by  Dr.  Langdon  Down,  and  with  ejoi- 
lepsy  and  other  forms  of  cerebral  deficiency  and  disturbance.  But  these 
do  not  appear  to  be  an  essential  part  of  the  disease  ;  indeed,  in  most  re- 
corded cases  the  cerebral  functions  have  been  unimpaired. 

The  course  of  the  disease  is  fairly  constant,  and  the  age  at  which  the 
illness  reaches  its  fatal  termination  varies,  as  a  rule,  according  to  the  age 
when  the  symptoms  first  appeared.  Thus,  if  the  symptoms  have  occurred 
in  infancy,  the  power  of  standing  is  lost  about  the  tenth  or  twelfth,  and 
death  ensues  between  the  fourteenth  and  eighteenth  years.  If  the  early 
symptoms  have  been  delayed  until  the  sixth  or  eighth  year,  the  patient  is 
less  incapacitated  b}'  the  time  puberty  is  reached,  and  may  live  to  the  age 
of  nineteen  or  twenty,  or  even  longer.  Still,  sometimes  the  disease  runs  a 
shorter  course,  and  it  may  happen  that  although  late  to  appear  the  symp- 
toms develope  rapidly,  and  the  patient  quickly  loses  all  power  of  support- 
ing himself  upright.  Even  in  the  fatal  cases  death  is  only  indu-ectly  the 
consequence  of  the  hypertrophic  disease.  When  the  muscles  of  the  chest 
become  attacked,  the  inspiratory  power  is  greatly  enfeebled,  and  any  acci- 
dental lung  complication  soon  assumes  alarming  proportions.  In  fact,  it 
is  usually  to  bronchitis  or  pneumonia  that  the  fatal  termination  is  to  be 
directly  attributed. 

Diagnosis. — Inordinate  size  and  firmness  of  muscle  combined  with  ex- 
treme weakness  and  unsteadiness,  developing  slowly,  and  becoming  grad- 
ually more  and  more  marked,  without  cerebral  symptoms,  impairment  of 
sensation,  or  weakness  of  the  bladder  or  rectum,  are  the  most  characteristic 
features  of  the  disease.  The  peculiarities  of  attitude  and  gait  are  also  to 
be  noted.  The  position  of  the  child,  as  he  stands  with  his  feet  widely  apart, 
his  abdomen  protruded  and  his  shoulders  thrown  back,  his  rolling  gait  in 
walking,  and  his  method  of  helping  to  straighten  the  knees  by  pressing 
with  his  hands  upon  the  femur  just  above  the  joint,  must  not  be  overlooked. 

Hypertrophy  of  the  muscles  is  not  always  present.  Largeness  and 
hardness-  of  the  calves  are  very  characteristic,  but  scarcely  any  less  charac- 
teristic are  their  contraction  and  wasting  with  drawing  up  of  the  heels. 
Di\  Gowers  attaches  great  importance  in  diagnosis  to  the  increased  size  of 
the  infra-spinatus  muscle,  with  wasting  of  the  latissimus  dorsi  and  lower 
part  of  the  pectoralis  major. 

There  is  little  difficulty  in  distinguishing  the  disease  from  infantile 
spinal  paralysis,  which  comes  on  quite  suddenly,  in  which  the  paralysis,  at 
first  general,  quickly  hmits  itself  to  certain  muscles,  faradic  contractility 
early  disappears,  and  wasting  is  rapid  and  extreme ;  nor  from  spasmodic 
spinal  paralysis,  in  which  spasm  is  a  marked  feature,  with  great  rigidity  of 
joints  and  exaggeration  of  the  tendinous  reflexes.  It  is  more  difficult  to 
decide  between  this  affection  in  its  early  stage  and  cerebellar  tumour,  or 
the  indefinite  beginning  of  intracranial  disease  in  well-nourished  children 
— cases  where  sometimes  all  that  can  be  detected  is  that  the  child  is  giddy 
and  falls  about.  Still,  in  pseudo-hypertrophic  paralysis  the  attitude  is  un- 
mistakable, and  the  way  in  which  the  child  rises  from  the  ground  can 
scarcely  be  misinterpreted.     Progressive  muscular  atrophy  is  so  excessively 


388  DISEASE   IN   CHILDEETT. 

rare  in  childhood  that  it  may  be  left  out  of  consideration.  It  differs  mark- 
edly from  the  disease  we  are  considering  by  being  never  attended  by 
muscular  pseudo-hypertrophy,  and  by  invariably  beginning  in  the  upper 
part  of  the  body.     In  a  child  seen  by  Duchenne  it  began  in  the  face. 

Prognosis. — When  the  disease  is  confirmed  we  can  scarce^  hope  by 
any  remedial  measures  to  stop  the  progress  of  the  muscular  change.  If 
the  patient  be  seen  at  an  early  period  of  the  attack,  before  any  enlargement 
of  the  muscles  has  been  noticed,  treatment  is  said  to  afford  more  hope  of 
success.  In  estimating  the  chances  of  a  lengthened  coru'se  we  must  take 
into  consideration  the  period  at  which  the  first  sjTnptoms  were  noticed, 
the  rate  at  which  the  affection  is  advancing,  and  the  age  and  sex  of  the 
patient.  According  to  Dr.  Gowers,  the  progress  of  the  disease  appears  t& 
be  often  related  to  the  process  of  growth  ;  therefore  the  less  the  muscular 
change  has  advanced  at  a  period  when  the  growth  of  the  body  is  com- 
pleted, the  greater  the  likelihood  that  the  disease  will  become  stationaiy. 
As  a  rule,  when  it  appears  late  it  advances  slowly.  Therefore  in  the  most 
favourable  cases  the  affection  has  appeared  late,  and  has  advanced  but  httle 
at  the  time  of  full  growth  of  the  body.  As  these  conditions  are  more  often 
found  rmited  in  gu-ls  than  in  boys,  the  female  sex  is  in  itself  a  favourable 
element  in  the  prognosis. 

Treatment. — There  is  little  to  be  done  in  the  way  of  treatment.  Du- 
chenne states  that  he  has  succeeded  in  arresting  the  disease  in  two  cases  bj 
means  of  faradism,  kneading  and  shampooing  the  muscles,  and  the  use  of 
baths.  Benedikt  recommends  the  continuous  cui*rent.  Ai'senic  and  phos- 
phorus given  internally  have  been  thought  to  be  useful  by  some.  Supports 
to  the  spine  are  of  service  when  there  is  great  weakness  of  the  back,  and 
in  cases  of  marked  contraction  of  the  calf  muscles  the  tendo  AchiUis  has 
been  divided  with  great  temporary  advantage. 


CHAPTER  XIX. 

IDIOCY. 

Mental  feebleness  or  deficiency,  either  congenital  or  acquired,  is,  unfortu- 
nately, a  far  from  uncommon  defect  in  childhood.  The  subject  is  an  im- 
portant one  to  the  physician,  for  although  he  may  not  be  called  upon  to 
treat  such  cases,  he  is  often  consulted  upon  the  chances  of  recovery,  and 
every  degree  of  feebleness  of  mind,  but  especially  the  milder  forms  of  im- 
becihty  and  mere  backwardness,  may  be  brought  under  his  notice. 

Causation. — Heredity  plays  a  very  important  part  in  the  production  of 
mental  deficiency  in  the  child.  Imbeciles,  fortunately,  do  not  often  marry, 
but  a  tendency  to  neurotic  disease,  such  as  insanity,  epilepsy,  etc.,  in  the 
parents  has  a  powerful  influence  in  inducing  feebleness  of  mind  in  their 
offspring.  Dr.  Langdon  Down,  from  careful  investigation  in  two  thousand 
cases  of  idiocy,  found  that  in  no  less  than  forty-five  per  cent,  a  well-marked 
neurosis  existed  in  the  families  of  one  or  both  the  parents. 

The  scrofulous  diathesis  has  been  said  to  favour  the  occurrence  of 
idiocy  ;  and  there  is  no  doubt  that  a  large  proportion  of  imbeciles  are  the 
subjects  of  scrofulous  cachexia.  Still,  mental  feebleness  is  not  a  necessary 
part  of  the  diathetic  disease  ;  indeed,  children  of  very  evident  scrofulous 
constitution  often  display  exceptional  intelligence.  The  explanation  may 
probably  be  that  the  scrofulous  habit  tends  to  foster  the  influence  of  a 
neurotic  tendency,  and  that  the  latter  will  operate  with  greater  force  and 
certainty  in  cases  where  it  is  associated  with  malnutrition  in  any  of  its 
forms.  So,  also,  consanguineous  marriages,  and  intemperance  on  the 
part  of  the  parents,  are  well-known  agencies  in  giving  increased  energy  to 
any  hereditary  neurosis  or  morbid  taint.  Therefore  any  instabihty  of  the 
nervous  system  which  may  exist  in  such  persons  is  likely  to  develope  into 
a  new  and  more  striking  j)hase  in  their  offspring. 

The  above  influences  are  influences  of  a  very  general  kind,  and  all 
children  born  of  the  same  parents  must  be  equally  subject  to  them.  Idiots 
are  seldom  "  only "  children  ;  indeed,  statistics  show  that  they  are  often 
born  of  more  than  ordinarily  prolific  parents  whose  other  children  exhibit 
no  sign  of  intellectual  deficiency.  This  being  so,  we  must  look  for  other 
and  more  special  causes  for  their  mental  failing. 

These  special  causes  may  either  operate  during  gestation,  at  the  time 
of  birth,  or  after  the  child  is  born. 

It  is  a  suggestive  fact  that  out  of  the  two  thousand  cases  investigated 
by  Dr.  Langdon  Down  no  less  than  twenty-four  per  cent,  were  primiparous 
children.  The  cause  of  this  undue  preponderance  in  the  first-born  is  no 
doubt  owing,  as  Dr.  Down  points  out,  not  only  to  the  exalted  emotional 
state  of  the  mother  during  her  first  pregnancy — a  state  in  which  all  causes 
■of  disturbance  would  naturally  operate  with  exceptional  force,  but  to  the 
tediousness  of  the  first  labour,  which  is  apt  to  give  rise  to  a  condition  of 
suspended  animation  in  the  infant.     Dr.  Down's  statistics  well  illustrate 


390  DISEASE  IN"   CHILDEEIS^. 

the  force  of  these  influences.  Twenty  per  cent,  of  the  idiots  were  bom 
with  well-marked  symptoms  of  suspended  animation  ;  and  of  idiots  bom  in 
this  condition,  and  only  resuscitated  by  assiduous  labour,  no  less  than  forty 
per  cent,  were  fii'st-born  children.  Bearing  upon  the  same  matter  is  the 
fact  of  the  preponderance  of  male  over  female  idiots,  for  the  larger  head 
of  the  former  would  increase  the  difficTilty  of  parturition,  and  conduce  to 
the  state  of  suspended  animation  which  experience  shows  to  be  so  hurtful 
to  the  cerebral  functions. 

Whether  the  mother  be  a  primipara  or  not,  powerful  emotional  shocks 
are  injurious,  and  may  act  very  unfavourably  upon  her  offspring.  In  no 
less  than  thirty-two  per  cent,  of  Dr.  Down's  cases  thei'e  was  a  well-founded 
history  of  mental  shock.  Again,  excessive  sickness,  by  impaii'ing  the 
mother's  nutrition,  is  also  calculated  to  exercise  an  unfavourable  influence 
upon  the  intellectual  development  of  her  infant.  Dr.  Langdon  DoviTi 
found  in  ten  j^er  cent,  of  his  cases  a  histoiy  of  marked  and  persistent 
vomiting. 

After  the  child  is  born  other  causes  come  into  operation.  The  mental 
incapacity  may  develope  at  a  constitutional  crisis,  siich  as  the  time  of  the 
first  or  second  dentition,  or  of  puberiy  ;  the  amount  of  bi*ain-power  which 
had  been  previously  sufficient  for  the  wants  of  the  economy  failing  to  cany 
it  through  such  critical  periods  of  develoj^ment.  •  Masturbation  in  these 
cases  may  be  an  important  factor  in  determining  the  break-doAvn.  Again, 
accidental  causes  may  come  into  oi3eration  in  a  child  who  had  never  shown 
symptoms  of  mental  failure.  Thus,  he  may  become  idiotic  as  a  result  of 
repeated  convulsions  or  epileptic  attacks,  of  clu'onic  hydrocephalus,  of 
injuries  or  blows  upon  the  head,  of  some  inflammatory  condition  occur- 
ring as  a  comphcation  of  acute  disease,  and  of  impaii-ment  of  the  senses- 
interfering  with  the  development  of  the  intellectual  faculties. 

One  form  of  idiocy— cretinism — is  endemic  in  certain  paris,  although  it 
may  also  occur  sj^oradically. 

Morbid  Anatomy. — In  most  cases  of  idiocy — in  all  in  which  the  mental 
deficiency  is  congenital — the  brain  is  small  and  often  imperfectly  developed 
as  well.  There  may  be  great  simplicity  in  the  convolutions,  approaching 
to  the  condition  of  the  brain  in  the  anthroj)oid  apes  ;  there  may  be  atroj)hy 
of  the  medulla  oblongata,  and  asymmetry  of  the  base  of  the  brain  ;  ab- 
sence of  the  corpora  geniculata,  the  corpus  caUosum,  or  even,  as  was  seen 
in  a  case  recorded  by  Cruveilhier,  the  whole  cerebellum  ;  the  convolutions 
may  be  shrunken  and  the  brain  substance  hardened.  In  other  cases 
the  child  may  be  from  bu'th  the  subject  of  chronic  hydrocephalus.  The 
brain  is  sometimes  abnormally  large,  but  may  present  no  obvious  change 
to  the  naked  eye.  Still,  from  the  researches  of  Dr.  M.  Jastrowitz  it 
seems  that  even  in  these  cases  careful  microscoj)ic  examination  may  detect 
alterations  in  structure  in  the  minute  tissues  of  the  brain,  especially  a 
persistence  of  anatomical  elements  which  are  normal  in  the  embryo,  but 
which  ought  to  have  passed  into  another  form  in  the  growing  ^hild. 

Again,  there  may  be  cranial  as  well  as  cerebral  abnormalities.  The 
sutures  and  fontanelles  may  undergo  prematui^e  coalescence ;  and  if  there 
be  no  compensation  by  unusually  slow  ossification  at  the  base,  allowing  of 
gi'eater  expansion  in  that  region,  the  entire  cranium  is  well  proportioned 
but  very  small,  and  profound  disturbance  of  the  growth  of  the  brain  is  the 
consecjuence.  If,  however,  there  be  basic  expansion,  a  special  tyjoe  of 
physiognomical  and  physical  development,  which  Griesinger  has  described 
as  the  "Aztec"  tyj^e,  results.  When  the  base  of  the  cranium  is  shortened 
by  ossification,  it  is  indicated  to  the  eye  by  malformation  of  the  face.     We 


IDIOCY — VARIETIES — SYMPTOMS.  391 

find  the  eyes  widely  separated,  a  prominent  ridge  to  the  nose,  and  high 
and  prominent  cheek-bones.  There  may  be  actual  microcephalus,  and  the 
development  of  the  pons  and  medulla  is  often  affected.  Usually,  however, 
a  certain  compensation  is  found  in  extension  of  the  skull  in  different  di- 
rections, producing  many  varieties  in  the  shape  of  the  cranium,  and  allow- 
ing of  more  or  less  expansion  of  the  brain  in  the  upper  regions. 

Varieties. — Many  different  methods  of  classification  of  idiots  have  been 
proposed.  There  is  the  psychical  classification  of  Esquirol,  in  which  the 
idiot  is  arranged  into  three  classes,  accoi'ding  to  the  degree  of  speech  of 
which  he  is  capable.  The  first  class  includes  those  who  use  mei-ely  words 
and  short  phrases.  The  second  class  consists  of  those  who  can  articulate 
monosyllables  or  certain  cries.  To  the  third  class  are  referred  those  who 
are  capable  of  articulating  neither  words  nor  monosyllables. 

Idiots  may  be  also  an-anged  into  three  classes  according  to  the  devel- 
opment of  nervous  function.  A  first  class  exhibits  nothing  beyond  the  re- 
'  flex  movement  known  as  excito-motor.  In  a  second  class  the  reflex  acts 
are  consensual  or  sensori-motor,  including  those  of  an  ideo-motor  or 
emotional  character.  In  a  third  class  we  see  manifest  volition  ;  their  ideas 
produce  some  intellectual  operations  and  consequent  will. 

Another  classification  is  that  suggested  by  Dr.  Langdon  Down,  accord- 
ing to  their  resemblance  to  ethnological  types — the  Caucasian,  Ethiopian, 
Malay,  and  Mongolian.  Dr.  Down  has  also  proposed  a  good  practical 
classification,  based  on  etiology,  into  1,  Congenital ;  2,  Developmental ;  3, 
Accidental. 

The  congenital  group  embraces  all  those  cases  where  the  signs  of 
mental  deficiency  date  from  birth,  and  includes  as  subdivisions  :  a,  Stru- 
mous ;  b,  Microcephalic ;  c,  Macrocephalic  ;  d,  Hydrocephalic ;  e,  Eclampsic  ; 
f,  Epileptic  ;  g,  Paralytic ;  h,  Choreic. 

The  developmental  idiot  is  a  child  who  is  borji  with  a  fair  amount  of 
brain  powder,  but  who  breaks  down  at  one  or  another  of  the  developmental 
crises— at  the  first  or  second  dentition  or  at  puberty.  Such  children  lose 
the  power  of  speech  and  their  minds  seem  to  give  way  at  one  of  these  evo- 
lutional stages.  The  group  includes,  as  subdivisions  :  a,  Eclampsic  ;  b. 
Epileptic  ;  c.   Choreic. 

In  accidental  idiocy  the  mental  break-down  is  the  consequence  of  some 
shock  or  traumatic  injury,  or  disease  operating  upon  a  healthy  child  born 
free  from  any  tendency  to  intellectual  deficiency.  This  group  includes  : 
a,  Traumatic  ;  b,  Inflammatory  ;  c.  Epileptic. 

Symptoms. — In  cases  of  congenital  idiocy  the  baby  begins  from  an 
early  age  to  show  that  he  is  not  the  same  as  other  infants.  The  develop- 
ment of  his  faculties  does  not  run  the  ordinary  course.  He  cannot  support 
his  head  like  another  child,  biit  lets  it  hang  back  on  his  nurse's  arm. 
Then,  he  takes  little  notice.  A  healthy  infant  will  often  recognise  his 
mother  by  the  sixth  week  ;  but  long  after  that  period  the  idiot  child  shows 
no  recognition  of  faces.  His  eyes  have  a  vacant  look,  seem  incapable  of 
fixing  upon  an  object,  and  often  oscillate  from  side  to  side  (nystagmus). 
Again,  he  does  not  smile  or  laugh  as  a  child  will  do  whose  mental  develop- 
ment is  advancing  naturally  ;  and  manifests  a  strange  inability  to  grasp 
with  the  hand.  A  healthy  child's  fingers  curl  round  any  object  presented 
to  them  at  a  very  early  age,  but  the  idiot  infant  seems  to  have  no  power 
of  making  any  use  of  his  hands.  Moreover,  when  danced  up  and  down, 
his  muscles  do  not  contract  in  sympathy  with  the  movement.  He  seems  to 
derive  no  pleasure  from  the  exercise,  but  remains  a  dead  weight  like  a 
heavy  doll. 


392  DISEASE  IN   CHILDEElSr. 

The  head  is  usually  noticed  to  be  peculiar  in  shape  from  an  early  age. 
It  is  often  high  in  the  crown,  and  perhaps  the  fontanelles  are  closed,  ot 
nearly  so,  at  the  end  of  six  months.  Again,  from  the  investigations  of  Dr. 
Langdon  Down  it  appears  that  a  high-vaulted  palate — the  V-shaped  palate 
— with  a  very  narrow  transverse  diameter  is  a  common  deformity  of  the 
congenital  idiot.  The  tongue  is  often  corrugated  with  transverse  furrows, 
and  sometimes  is  not  completely  under  command.  It  hangs  out  of  the 
mouth,  and  the  child  dribbles  in  an  unusual  degree  even  for  a  baby.  The 
teeth  are  commonly  late  in  being  cut  and  often  appear  irregularly. 

At  twelve  months  old,  when  the  child  should  be  able  to  stand,  or  should 
at  least  crawl  on  the  floor  and  try  to  raise  himself  on  to  his  feet,  he  lies 
just  as  he  is  put  down,  without  an  attempt  to  move  himself  along.  Often 
he  does  not  learn  to  walk  until  he  is  three  or  four  years  old.  It  is  also 
difficult  to  teach  him  cleanly  habits,  and  he  remains  infantine  in  his 
ways  at  an  age  when  other  childi-en  have  long  been  taught  decency  and 
order. 

When  idiocy  is  congenital,  growth  and  development  are  impaired  as 
well  as  mental  power,  and  the  general  health  is  far  from  satisfactory.  The 
patient  is  stunted  in  his  stature  and  looks  yoimger  than  his  age.  The  cir- 
culation is  often  feeble,  and  the  temperature  a  degree  or  two  lower  than 
that  of  health.  The  feet  are  cold.  The  heart  is  frequently  small  and  weak 
in  structure,  and  there  may  be  an  open  foramen  ovale  or  other  congenital 
deficiency.  Often  other  malfoi-mations  are  seen,  as  imperfect  development 
of  one  or  more  fingers,  a  club  foot,  or  some  strange  shape  of  the  ears. 
Such  children  may  show  signs  of  rickets,  and  are  not  seldom  of  decidedly 
scrofulous  constitution.  As  they  grow  up,  an  unpleasant  smell  is  often 
noticed  about  the  body  and  breath.  In  bad  cases  automatic  movements 
are  present  ;  chorea  and  epileptic  fits  are  common  comphcations,  and  the 
senses  are  frequently  dull. 

Griesinger  describes  two  special  varieties  of  idiots— the  apathetic  and 
the  excited. 

The  apathetic  class  are  awkward,  clumsy,  and  disproportioned,  with  re- 
pulsive, old-looking  features.  From  theii-  torpor  and  impassiveness  they 
seem  to  be  in  a  dreamy  state.  Their  expression  is  either  brooding  and 
melancholy,  or  vacuous  and  indifferent. 

The  excited  or  agitated  class  are  just  as  stupid  as  the  other,  but  are 
quick  in  movement  and  irritable,  passing  rapidly  from  one  impression  to 
another,  and  quite  incapable  of  fixing  anything  on  their  mind. 

Between  these  two  principal  groups  there  are  many  intermediate  va- 
rieties. 

There  is  one  form  of  idiocy,  endemic  in  some  countries,  sporadic  in 
others,  which  merits  a  separate  description.  This  is  cretinism.  The  fee- 
bleness of  intellect  fi'om  which  cretins  suffer  is  combined  with  striking- 
peculiarities  of  bodily  structure.  The  condition  is  always  congenital.  It 
is  not  hereditary  in  the  ordinary  sense,  although  where  the  other  conditions 
inducing  the  disease  prevail,  the  child  will  become  cretinous  more  certainly 
if  born  of  cretinous  parents.  The  disease  has  been  said  to  be  dependent 
upon  the  general  causes  of  ill  health — bad  air,  bad  water,  imperfect  di'ain- 
age,  insufficient  light  and  poor  food,  combined  with  the  use  of  water 
loaded  with  calcareous  salts.  It  may  therefore  prevail  in  any  quarter  of 
the  world  where  these  conditions  are  found ;  and  certain  close  valleys  in 
the  Alps,  Pyrenees,  and  Himalaya  mountains  are  especially  notorious  for 
the  number  of  cretins  born  in  them.  The  value  of  these  causes  in  produc- 
ing the  condition  has,  however,  been  called  in  question.    Perhaps  it  is  best 


IDIOCY — CEETIlSriSM — SYMPTOMS.  393 

to  say  that  nothing  positive  is  known  with  regard  to  the  etiology  of  the  dis- 
ease. Whatever  the  cause  may  be,  it  appears  to  be  also  the  cause  of  goitre, 
for  cretinism  and  goitre  are  frequently  associated.  It  has  been  said  that  act- 
ing feebly  the  causes  jDroduce  goitre,  acting  strongly  they  give  rise  to  cre- 
tinism ;  but  even  this  is  hypothesis.  Cretins  are  not  invariably  goitrous.  In- 
deed, in  sporadic  cases,  such  as  occur  from  time  to  time  in  London,  it  is  not 
uncommon  to  find  that  the  thyroid  body  is  absent.  In  two  cases  which  came 
under  my  own  notice  no  trace  of  a  thyroid  body  could  be  detected.  It  is 
in  places  where  cretinism  is  endemic  that  it  is  usually  complicated  with 
goitre  ;  but  even  in  such  neighbourhoods  the  goitre  is  not  confined  to  cre- 
tinous subjects  ;  and  the  area  over  which  goitre  is  endemic  is  much  larger 
than  that  in  which  cretinism  is  prevalent. 

Vu-chow's  researches  have  done  much  to  elucidate  the  chief  feature  of 
cretinism.  According  to  this  authority,  it  consists  in  an  abnormal  tendency 
to  ossification  and  coalescence  of  the  three  bones  which  represent  the 
bodies  of  the  last  three  cranial  vertebrae,  viz.,  the  basUar  process  of  the  oc- 
cipital bone,  the  post-sphenoidal,  and  the  prse-sphenoidal  bones.  In  the 
normal  condition  ossification  in  these  bones  goes  on  slowly  from  behind 
forwards,  and  trafces  of  unossified  cartilage  may  be  found  as  late  as  the 
thirteenth  year.  During  the  whole  of  this  time  the  cartilaginous  parts 
are  still  growing,  and  allow  of  expansion  of  the  base  of  the  skull  and  en- 
largement of  the  cranial  cavity  in  proportion  to  the  wants  of  the  growing 
brain.  In  the  cretin,  in  whom  ossification  in  these  parts  takes  place  early, 
the  base  of  the  skull  cannot  elongate  ;  the  distance  from  the  crista  galli  to 
the  occipital  foramen  remains  short ;  the  corresponding  parts  of  the  brain 
are  imperfectly  developed,  and  the  form  of  the  skull  is  modified.  Moreover, 
the  bones  of  the  skull  are  in  many  cases  greatly  thickened  and  the  fora- 
mina narrowed.  The  bones  of  the  limbs  frequently  show  the  same  ten- 
dency to  rajpid  ossification,  and  the  shafts  form  early  union  with  their 
epiphyses.  Consequently,  the  gTowth  of  the  bones  is  imperfect.  The 
"brain  undergoes  many  modifications.  Important  parts,  such  as  the  gan- 
glia at  the  base,  are  often  ill  developed,  the  medulla  oblongata  may  be 
small,  and  the  fissure  of  Sylvius  shallow  and  ill  defined. 

The  physical  and  mental  characteristics  of  the  cretin  are  well  illustrated 
by  a  case  which  was  under  my  care  in  the  East  London  Children's  Hospi- 
tal. The  patient  was  a  little  girl,  aged  seven  years,  who  had  come  of  a 
healthy  family  on  both  sides.  She  had  five  perfectly  healthy  brothers  and 
sisters.  The  family  lived  in  Shadwell,  in  the  neighbourhood  of  the  hospi- 
tal. The  child  was  said  to  have  been  a  fine  baby  at  birth,  but  as  the 
months  passed  no  teeth  appeared,  and  she  showed  no  inclination  to  stand 
or  even  crawl  upon  tbe  floor.  She  generally  seemed  very  dull  and  apa- 
thetic, but  sometimes  brightened  up  and  became  more  lively. 

At  seven  years  of  age,  when  admitted  into  the  hospital,  she  was  barely 
thirty-one  inches  in  height.  She  looked  very  broad  for  her  height,  and 
weighed  thirty-one  pounds  eight  ounces.  Head  large,  nineteen  inches  in 
circumference,  covered  by  long,  sparse,  coarse  hair  of  a  dull  reddish- brown 
colour ;  features  large  and  coarse  ;  bridge  of  nose  depressed  ;  eyes  wide 
apart ;  lips  thick  and  pouting ;  mouth  generally  kept  half  open  ;  teeth 
square,  as  if  worn  down  ;  tongue  large  ;  eyes  gray  and  dull-looking  ;  expres- 
sion vacant  as  a  rule,  but  sometimes  brightening  up  when  amused  with 
a  doll  or  ball.  No  trace  of  a  thyi'oid  gland  could  be  discovered  ;  above 
each  clavicle  was  a  semi-globular  mass,  about  the  size  of  a  Tangerine 
orange.  The  skin  was  rather  dry  and  shrivelled-looking,  with  a  yellowish 
tint.     The  chest  was  well  formed.     There  was  no  beading  of  the  ribs  or 


394  DISEASE   IN   CHILDEElSr. 

other  sign  of  rickets.  The  tibise  were  somewhat  bowed  outwards,  but  the 
limbs  were  massive  and  the  ilesh  firm. 

The  child  smiled  when  spoken  to,  and  could  say  the  word  "doll,"  but 
appeared  to  apply  it  indifferently  to  all  kinds  of  toys.  She  could  not  walk, 
but  crawled  about  on  her  hands  and  feet,  keeping  her  knees  raised. 
When  she  reached  a  table  or  bed,  she  would  raise  herself  into  an  upright 
position  with  her  hands  and  stand  holding  by  it.  The  child  passed  urine 
and  faeces  in  the  bed.     Her  temperature  was  habitually  subnormal. 

The  soft  globular  lumps  above  the  clavicles  are  frequent  in  the  sporadic 
form  of  cretinism.  In  Mr.  Curling's  cases  they  were  found  after  death  to 
consist  of  fatty  tissue. 

In  another  case  which  came  under  my  notice  the  patient,  who  had  the 
appearance  of  a  child,  was  really  over  seventeen  years  of  age.  His  height 
was  half  an  inch  under  three  feet,  his  weight,  thirty-six  pounds  fourteen 
ounces.  He  had  all  the  physical  peculiarities  described  in  the  previous 
case,  but  was  more  intelligent  and  cleanly  in  his  habits.  He  could  answer 
simple  questions  as  to  his  food  intelUgibly.  He  had  the  same  fatty 
masses  in  the  supraclavicular  hollows,  and  no  thyroid  body  could  be 
felt.  His  genitals  were  those  of  a  child,  and  he  never  manifested  any 
sexual  propensities. 

The  symptoms  of  cretinism  seldom  appear  before  the  sixth  or  seventh 
month.  The  head  is  usually  large,  for  cretins  never  belong  to  the  micro- 
cephalic type.  The  palate  is  often  flat,  and  not  highly  arched,  as  in  ordinary 
congenital  idiocy.  These  patients  are  usually  quiet  and  good-tempered, 
although  subject  to  occasional  fits  of  passion.  Their  senses  are  often  dull, 
and  they  endure  great  cold  and  heat  without  apparent  discomfort.  It  is, 
however,  one  of  the  characteristics  of  idiots  generally  that  their  senses  are 
obtuse  :  they  can  often  bear  pain  with  singular  indifference ;  their  taste  is 
not  uncommonly  impaired  or  perverted,  and  sometimes  they  have  but  a 
faint  sense  of  smell.  Often  their  sight  is  defective  from  congenital  cata- 
ract, or  imperfect  sensibility  of  the  retina,  or  hypermetropia  with  diminished 
accommodation  ;  but  unless  they  have  suffered  from  disease  of  the  ear,  their 
hearing  is  usually  of  normal  acuteness. 

The  mental  condition  of  idiots  has  many  varieties.  In  the  lowest  form 
there  is  complete  apathy  and  torpor  ;  no  power  of  attending  to  or  even 
recognising  their  own  wants,  and  no  capacity  to  speak  or  to  understand 
words  spoken  to  them.  Such  beings  can  only  make  unintelligible  noises. 
They  have  not  the  slightest  powder  of  will,  and  seem  to  have  little  power  of 
originating  a  movement,  but  often  repeat  mechanical^  some  automatic 
motion  of  the  head,  the  body,  or  a  limb. 

At  the  other  end  of  the  scale  is  mere  feebleness  of  mind.  Such  chil- 
dren can  be  taught  to  read,  and  are  capable  of  great  improvement  by  kind- 
ness and  perseverance.  Even  in  the  higher  class  of  idiots  speech  is 
usually  defective,  partly  from  malformation  of  the  mouth  ;  partly  from 
want  of  co-ordination  of  the  lingual  muscles  ;  but  chieflj',  no  doubt,  from 
the  poverty  o'f  their  vocabulary,  and  the  small  stock  of  words  to  which  they 
attach  any  definite  meaning.  In  all  the  severer  forms  of  idiocy  no  attempt 
at  speech  is  ever  made  ;  and,  as  Griesinger  observes,  the  idiot  who  does 
not  speak  has  no  internal  idea  of  speech,  and  is  therefore  "deficient  in  the 
most  essential  element  in  the  mechanism  of  abstraction." 

Idiocy  has  been  described  as  a  fixed  infantile  condition,  and  the  idiot 
has  been  compared,  as  regards  intelligence,  with  a  healthy  child  of  so  many 
months  or  years  of  age.  An  idiot,  however,  is  not  merely  a  backward 
child.     With  him  volition  is  feeble  or  quite  absent ;  and  he  has  little 


IDIOCY — DIAGNOSIS.  395 

imagination  or  power  of  abstract  thought.  Therefore,  although  his  actual 
degree  of  intellectual  development  may  correspond  with  that  of  the  younger 
child,  there  is  a  something  still  wanting,  which  if  wanting  in  the  child  with 
whom  he  is  compared  would  occasion  very  serious  anxiety.  Sometimes 
one  faculty  is  developed  in  idiots  to  the  exclusion  of  all  others.  In  all 
treatises  on  this  subject  instances  are  given  showing  remarkable  aptitude 
for  music,  drawing,  and  reckoning  ;  also  for  various  forms  of  mechanical 
cousti'uction  as  carpentering,  model-making,  etc. 

Diagnosis. — Idiocy  must  be  distinguished  from  mere  backwardness, 
and  also  from  cases  where  the  development  of  the  mental  faculties  suffers 
through  deficiency  in  the  sense  of  hearing. 

Mere  backwardness,  even  when  present  in  a  marked  degree,  is  far  re- 
moved from  idiocy.  The  class  of  backward  children  presents  many  points 
of  interest.  The  delay  in  development  is  usually  physical  as  well  as  men- 
tal. They  are  smaU  but  not  usually  deformed  ;  and  there  is  no  symptom 
of  disease  of  brain  or  disorder  of  mind.  They  are  simply  backward  chil- 
dren in  whom  progress  of  every  kind  takes  place  very  leisurety.  Instead  of 
learning  early  to  walk,  and  picking  up  words  and  ideas  with  the  quickness 
of  a  healthy  child,  they  are  slow  to  walk,  slow  to  talk,  slow  to  quit  the 
habits  and  helplessness  of  the  baby  for  the  decency  and  independence  of 
later  childhood.  Still,  they  do  not  remain  stationary  like  the  idiot ;  they 
do  learn,  although  slowly  ;  and  with  jDatience  can  be  taught  in  time  much 
that  forms  the  education  of  a  child  of  ordinary  capacity.  Backward  chil- 
dren, however,  sometimes  become  idiotic.  If  they  happen  to  be  also  epi- 
leptic or  addicted  to  self-abuse,  they  may  gradually  become  duller  and 
duller  and  fall  into  a  state  of  complete  idiocy. 

In  all  cases  of  backwardness,  especially  of  lateness  of  talking,  with  ap- 
parent dulness  of  mind,  the  state  of  the  hearing  should  be  inquired  into. 
A  child  who  hears  imperfectly  is  always  slow  in  acquiring  the  power  of  ar- 
ticulation ;  and  besides,  as  Dr.  West  has  pointed  out,  his  difficulty  with 
this  defect  of  keeping  up  intercourse  with  other  children  makes  the  patient 
dull,  suspicious,  and  unchildlike. 

Idiocy,  when  confirmed,  is  of  interest  chiefly  to  the  specialist.  The  ordi- 
nary practitioner  is  most  concerned  with  the  early  symptoms  of  mental  fee- 
bleness, as  this  is  seen  in  the  infant.  Nothing  is  commoner  than  for  the 
family  physician  to  be  consulted  because  the  baby  "does  not  seem  to  take 
notice." 

In  a  healthy  infant  the  senses  come  into  play  in  the  following  order : 
Sight  is  the  earliest  to  manifest  itseK.  A  fortnight  after  birth  the  infant's 
eyes  should  follow  a  light,  as  that  of  a  lamp  ;  and  at  the  end  of  a  month 
or  six  weeks  he  is  often  able  to  recognise  his  nurse  and  will  smile  when 
she  approaches.  During  the  first  few  weeks  babies  often  squint,  especially 
when  looking  at  a  near  object.  Later  they  become  more  expert  in  focus- 
ing their  eyes  to  suit  various  distances. 

The  child  seldom  gives  evidence  of  hearing  sounds  before  the  third 
month,  although  Darwin  states  that  his  infants  started  at  sudden  noises 
when  under  a  fortnight  old.  Babies  do  not  recognise  voices  imtil  after 
the  fourth  month,  and  it  is  the  eighth  or  ninth  month  before  they  begin  to 
recognise  objects  by  name. 

With  regard  to  movements  :  a  child  of  two  months  of  age  will  raise 
his  head  from  the  pillow  ;  and  after  the  third  month  will  begin  to  use  his 
hands  and  to  toss  up  his  head.  At  this  time  (the  third  month)  he  can 
support  his  head  well.  It  is  usually  the  ninth  month  before  the  child 
"  feels  his  feet,"  i.e.,  presses  his  soles  to  the  ground  when  held  to  the 


396  DISEASE  I]S'   CIIILDRE]S\ 

floor.  He  slioulcl  ■walk  some  time  between  the  tenth,  and  the  eighteenth 
month. 

A  healthy  infant  should  keep  his  tongue  within  his  mouth  from  the 
earhest  age.  His  fontanelle  should  not  close  before  the  eighteenth  month, 
nor  be  completely  ossified  before  the  end  of  the  second  year. 

The  faculty  of  speech  is  acquu-ed  much  more  quickly  by  some  children 
than  by  others.  Most  babies  will  begin  to  say  words  after  the  end  of  the 
first  year,  and  many  can  talk  freely  by  the  end  of  the  second. 

It  is  seldom  before  the  end  of  the  sixth  month  that  any  suspicion  is  felt 
that  all  is  not  right  with  the  infant's  mental  development.  Then  it  is 
usually  the  vacancy  of  his  expression,  the  absence  of  any  smile  to  greet  his 
mother's  approach,  some  peculiarity  in  his  way  of  taking  food,  and  the 
dead  weight  of  the  chUd  as  he  hes  with  his  head  back  in  his  nui'se's  arms 
that  first  excites  the  anxiety  of  the  parents.  In  such  cases  we  notice  the 
weakness  of  the  muscles  of  the  back  and  neck,  and  their  inabihty  to  sup- 
]Dort  the  head  or  keep  the  body  erect  for  a  moment,  the  nystagmus,  the 
vacant  look  in  the  eyes,  which  never  seem  to  fix  upon  an  object,  and  can- 
not be  made  to  follow  it  when  it  is  moved  before  them,  the  abnormal  flow 
of  saHva  fi'om  the  mouth,  and  the  passiveness  of  the  child's  hand  when  a 
finger  is  placed  in  it — so  difierent  from  what  occui's  with  the  healthy  baby 
who  at  once  squeezes  anything  which  touches  his  fingers.  On  inquiiy  we 
find  either  that  the  child  is  always  whining,  or  that  he  is  strangely  silent 
and  pays  no  attention  to  sounds  which  please  other  infants  of  his  age  ; 
also,  perhaps,  that  he  takes  the  breast  or  bottle  very  slowlj',  and  often  makes 
a  curious  choking  noise  at  the  back  of  his  nose.  In  such  cases  we  gener- 
ally find  that  the  palate  is  narrow  and  highly  arched  (the  V-shaped  palate)  ; 
that  the  head  is  small  and  of  a  curious  shape — unsymmetrical,  or  veiy  high 
and  narrow  in  the  crown  ;  that  the  fontanelle  is  excessively  small  or  quite 
closed  ;  that  the  hands  and  feet  tend  to  be  cold  ;  that  the  muscles  feel 
flabby,  and  on  examination  we  can  sometimes  discover  a  congenital  heart 
complaint,  a  club  foot,  or  some  other  form  of  congenital  deformity.  Dr. 
Langdon  Down  has  di'awn  especial  attention  to  the  appearance  and  posi- 
tion of  the  ear.  A  helix  or  the  lobule  may  be  quite  absent,  and  the  j)inna 
is  often  planted  farther  back  in  relation  to  the  head  and  face  than  ia  the 
healthy  child.  Dr.  Down  also  dii'ects  that  the  position  of  the  eye,  as  to 
obhc[ueness,  as  well  as  degree  of  separation,  should  be  noted,  as  there  is 
often  an  approach  to  the  ethnical  variety  described  by  this  physician  as 
the  Mongolian  type.  Also,  that  the  integument  about  the  ej'es  should  be 
examined  for  semilunar  folds  of  skin  at  the  inner  canthus  (epicanthic 
folds),  which  are  more  common  in  feeble-minded  infants  than  in  the  healthy. 

The  cretin  can  usually  be  recognised  without  difficulty  by  his  stunted 
gTowth ;  his  large  head ;  his  depressed  nose,  ^^^.th  widely  sejDarated  eyes  ;'  his 
dull,  heavy  expression  ;  wide  mouth,  broad  lips,  and  thick  tongue  ;  his  shi'iv- 
elled-looking  tawny  skin  ;  his  heavy  hmbs  and  awkward  walk.  If  the  disease 
is  endemic,  there  is  probably  a  goitre ;  if  sporadic,  we  notice  the  curious 
fleshy  elastic  masses  above  the  clavicles  and  the  absence  of  a  thp-oid  gland. 

Frogno.^is. — The  most  hopeful  cases  ai'e  those  in  which  the  defect  is  a 
congenital  one  ;  the  worst  ai-e  those  of  accidental  origin  who  bear  in  their 
faces  and  persons  httle  trace  of  theii-  infirmity.  Paralysis  or  epilepsy,  or 
other  form  of  nervous  instabihty,  increases  the  difficulty  of  the  case.  So, 
also,  general  feebleness  of  health  is  a  bar  to  improvement  ;  and  profound 
scrofulous  cachexia,  or  a  weak  heart  and  feeble  circulation,  render  the 
patient  less  responsive  to  systematic  training  than  another  whose  nutrition 
is  more  satisfactory. 


IDIOCY — PROGNOSIS — TEEATMEIS^T.  397 

Dr.  Edward  Seguin  regards  as  favourable  signs:  Steadiness  of  the 
walk,  which  deviates  little  from  the  centre  of  gravity  ;  a  hand  firm  without 
stiffness,  and  not  disturbed  by  automatic  movements — one  which  can  take 
and  leave  hold  at  command  ;  an  unimj)aired  state  of  the  senses,  especially 
a  look  which  is  easily  called  into  action  ;  a  command  of  the  words,  however 
imperfect  or  few,  which  the  child  may  possess,  so  that  they  have  a  con- 
nected meaning  and  come  out  oj)portunely  ;  activity  without  restlessness ; 
willingness  to  obey  ;  sensibility  to  praise,  and  capability  of  returning  as 
well  as  of  receiving  caresses. 

A  contrary  state  of  things  must  be  looked  upon  as  unfavourable.  More- 
over, if  some  feelings  of  affection  have  been  developed  by  kind  parents, 
and  are  not  followed  by  corresponding  intellectual  progress  ;  or  if  the 
idiocy  is  complicated  by  extensive  paralysis,  or  worse,  by  epilepsy,  the 
prognosis  is  very  bad. 

Treatment. — In  the  treatment  of  idiocy  our  first  care  should  be  to  attend 
to  the  general  health  of  the  patient,  so  that  he  may  be  put  physically  into 
as  good  a  condition  as  he  is  capable  of  reaching,  and  afterwards  to  incul- 
cate volition  and  co-ordinated  voluntary  movement  by  careful  physical 
training  ;  to  attend  to  his  moral  education,  and  do  what  can  be  done  to 
develop  his  intellect. 

It  is  very  important  that  the  idiot  should  be  removed  from  the  society 
of  healthy  children,  whose  games  he  cannot  share,  and  whose  companion- 
ship he  cannot  enjoy,  to  association  with  beings  affiicted  hke  himself,  in  the 
presence  of  whom  he  is  not  opj)ressed  by  a  j^ainful  sense  of  inferiority. 
It  is  indispensable  to  the  due  progress  of  the  feeble  in  mind  that  they 
should  be  received  into  asjdums  and  estabUshments  especially  devoted  to 
the  treatment  of  such  cases.  In  these  every  means  can  be  adopted  to 
counteract  the  scrofulous  tendencies  of  which  a  large  proportion  of  the 
patients  are  the  subjects.  The  building  can  be  erected  at  a  suitable  ele- 
vation on  a  porous  soil  of  sand  or  gravel.  The  rooms  and  passages  can  be 
large,  well  ventilated,  and  suitably  warmed.  Moreover,  a  proper  system  of 
bathing  and  shampooing  can  be  established  to  j)romote  the  healthy  action 
of  the  skin  and  invigorate  the  feeble  muscles. 

The  dietary  should  be  liberal,  and  presented  in  a  form  to  suit  the 
pecuharities  of  the  patient,  for  many  idiots  cannot  chew  their  food.  Some, 
indeed,  can  only  swallow  it  when  it  is  placed  far  back  on  the  tongue,  so 
that  it  may  come  within  the  grasp  of  the  pharyngeal  muscles. 

Residence  at  a  special  training  school,  it  is  generally  held,  should  begin 
when  the  patient  is  about  seven  years  of  age,  unless  the  existence  of  con- 
stitutional disease,  ejDileptic  fits,  or  other  complication  requiring  constant 
medical  supervision  necessitate  earlier  admission.  The  system  of  training 
can  be  divided  into  three  branches  :  physical,  moral,  and  intellectual. 

The  physical  training  consists  in  careful  education  of  the  muscles  by 
regular  co-ordinated  movements  which  bring  the  will  into  exercise,  and 
substitute  jDurposive  acts  for  the  aimless  automatic  motions  which  are  so 
characteristic  of  the  vacant  mind.  The  exercises  are  graduated,  and  pass 
from  the  simplest  movements  to  others  more  complex  in  character,  so  that, 
as  Dr.  Langdon  Down  observes,  "  the  idiot  builds  up  a  series  of  co-ordi- 
nated voluntary  movements  which  are  applicable  to  the  wants  of  daily 
life." 

Moral  education  teaches  the  child  obedience,  and  encourages  him  to 
endeavour  to  win  the  approval  and  retain  the  affection  of  his  teachers  by 
doing  what  he  is  told  is  right,  and  avoiding  what  he  is  told  is  wrong. 

The  intellectual  education  is  based  on  a  cultivation  of   the  senses. 


398  DISEASE   IK   CHILDREN. 

ToTicli  and  feeling  are  trained  to  appreciate  differences  in  tlie  form  ot 
objects,  beginning  with  simple  things  and  proceeding  gradually  to  the 
more  complex.  Sight  is  cultivated  by  making  the  patient  appreciate  light 
and  darkness,  and  accustoming  him  to  match  coloured  counters  or  stiing 
coloured  beads.  So  on  with  the  other  senses.  Everything  that  is  taught 
should  be  taught  in  the  beginning  in  the  simplest  way,  and  we  should 
make  siu-e  that  the  first  fact  has  been  thoroughly  grasped  before  we  pass 
on  to  the  second.  In  this  way  the  mind  is  educated  through  the  senses, 
and  in  time  by  patience  and  perseverance  astonishing  results  may  be  often 
obtained. 


Part  6, 
DISEASES  OF  THE  ORGANS  OF  RESPIRATION. 


CHAPTER  I. 

EXAMINATION   OF   THE   CHEST. 


The  affections  of  the  lungs  constitute  a  very  important  branch  of  the  dis- 
eases of  childhood.  The  study  of  these  complaints  must  no  doubt  present 
pecuhar  difficulties,  for  persons  who  are  fairly  conversant  with  the  ordinary 
maladies  of  early  life  will  often  profess  their  inability  to  understand  them. 
In  many  cases  an  examination  of  the  chest  in  a  child  cannot  be  carried 
through  without  much  tact  and  management ;  in  others  the  utmost  gentle- 
ness will  not  reconcile  the  patient  to  a  procedure  of  which  he  only  per- 
ceives the  inconveniences  ;  and  even  in  the  most  favourable  cases  the  ob- 
server meets  with  peculiarities  in  the  physical  signs  which  in  one  unaccus- 
tomed to  such  youthful  patients  may  give  rise  to  considerable  perplexity. 

In  order  to  examine  the  chest  of  a  child  with  success  the  patient  must 
be  raised  up  to  a  convenient  height.  If  we  stoop  down  to  a  child  as  he 
sits  upon  his  nurse's  lap,  our  own  position  is  cramped  and  uncomfortable. 
Fully  to  appreciate  minute  deviations  from  a  healthy  state  the  attitude  of 
the  observer  should  be  one  of  ease.  In  the  case  of  an  infant,  to  examine 
the  front  of  the  chest  the  child  should  be  laid  upon  his  back  on  a  cushion 
placed  upon  the  table.  Some  babies,  however,  cry  at  once  when  laid  upon 
the  back.  In  such  cases  the  patient  may  be  placed  in  a  sitting  position  on 
the  cushion  supported  by  the  nurse.  When  the  back  is  examined  the 
nurse  should  stand  up  and  take  the  child  on  her  left  arm,  so  that  his  head 
and  right  arm  hang  over  her  left  shoulder,  and  his  left  arm  is  loosely  ap- 
plied round  her  neck.  In  this  position  the  muscles  of  both  shoulders  are 
relaxed.  An  older  child  can  be  seated  upon  a  table  for  examination.  It 
is  needless  to  say  that  in  both  cases  the  patient  should  be  completely 
stripped  to  the  waist. 

Much  may  be  learned  from  mere  inspection  of  the  chest.  In  the  case  of 
an  infant  the  points  to  which  attention  should  be  directed  have  already 
been  referred  to  (see  page  12).  In  children  of  four  or  five  years  old  and  up- 
wards we  can  often  ascertain  by  this  means  the  existence  of  a  constitutional 
predisposition.  In  children  of  consumptive  tendencies  the  lungs  are  smaU. 
As  a  consequence  the  thorax  is  forced  to  adapt  itself  to  the  size  of  its  con- 


400  DISEASE   IN   CHILDREN. 

tents.  The  shoulders  are  narrow  and  slojDing  ;  the  ribs  are  very  oblique- 
and  the  chest  elongated  ;  and  the  scapulae  project  backwards  like  wings. 
The  prominence  of  the  shoulder-blades  has  given  the  name  of  "  alar  "  or 
"  pterygoid  "  to  this  variety  of  chest.  In  small-lunged  children,  and  chil- 
dren with  vulnerable  chests,  the  thorax  is  often  flattened  anteriorly,  so  as 
to  diminish  the  antero -posterior  diameter.  The  flattening  is  due  to  yield- 
ing of  the  costal  cartilages  under  the  pressure  of  the  atmosphere  when  the 
lungs  are  expanded  in  the  act  of  inspiration.  It  is  usually  the  consequence 
of  narrowing  of  the  air-tubes  from  catarrh  of  the  mucous  membrane.  If 
we  notice  the  shape  of  the  chest  to  correspond  to  either  of  these  types,  we 
must  examine  the  apices  very  carefaUy  for  signs  of  disease.  Moreover, 
in  the  treatment  of  even  the  simplest  pulmonary  derangement  in  such. 
cases  we  must  be  careful  to  follow  up  any  special  medication  by  invigorat- 
ing measures,  and  wait  for  complete  cessation  of  the  cough  before  per- 
mitting the  child  to  resume  the  ordinary  habits  of  health. 

If  we  notice  an  infra-mammary  depression  on  each  side  of  the  chest,, 
with  some  prominence  of  the  lower  part  of  the  sternum,  we  infer  that  the 
patient  has  been  subject  to  long-continued  or  frequently  repeated  attacks 
of  pulmonary  catarrh.  In  these  attacks  the  air-tubes  are  narrowed  by  the 
presence  of  catarrh,  so  that  air  penetrates  insufficiently  into  the  lungs,  and 
expansion,  especially  of  the  inferior  lobes,  is  incomplete.  As  a  consequence 
the  lower  ribs,  corresponding  to  the  imperfectly  inflated  tissue,  are  re- 
tracted at  each  descent  of  the  diaphragm.  As  the  lower  ribs  fall  in,  the 
lower  end  of  the  breast-bone  is  forced  forwards,  so  that  a  horizontal  sec- 
tion of  the  chest  at  this  point,  instead  of  elliptical,  would  be  triangular. 
After  a  succession  of  these  catarrhs  a  certain  amount  of  permanent  coUapse 
is  induced  in  the  lower  lobes,  and  the  deformity  becomes  a  permanent 
one.  The  prominence  of  the  sternum  from  this  cause  constitutes  one  of  the 
varieties  of  "pigeon-breast."  The  rickety  chest  is  also  pigeon-breasted,  as 
is  explained  elsewhere  (see  page  139). 

The  central  cup-shaped  depression  of  the  lower  end  of  the  sternum  and 
corresponding  cartilages,  sometimes  met  with,  has  been  referred  to  in  a 
previous  chapter  (see  page  12). 

The  movements  of  the  chest  in  inspiration  must  be  carefully  noted. 
Sometimes  we  find  a  general  exaggeration  of  movement  combined  with  im- 
perfect expansion  of  the  chest-waU.  This  abnormality  indicates  a  pressing 
want  of  air  from  some  impediment  to  the  efificient  expansion  of  the  lungs. 
"When  bilateral,  it  is  seen  in  cases  of  catarrhal  pneumonia,  in  advanced 
phthisis,  and  in  double  pleurisy  and  hydrothorax.  When  unilateral,  it 
may  be  produced  by  one-sided  pleurisy,  pneumothorax  (a  very  rare  condi- 
tion in  the  child),  extensive  fibroid  induration,  or  condensation  of  lung 
from  a  former  pleurisy  with  firm  pleural  adhesions. 

In  early  hfe  the  thoracic  walls  yield  readily  to  the  pressure  of  the  ex- 
ternal air,  and  this  pliancy  is  especially  noticeable  in  infants  and  rickety 
children.  Consequently  in  them  dyspnoea  is  often  indicated  by  more  or 
less  retraction  of  the  chest-wall  in  inspiration.  This  retraction  is  mostly 
in  the  infra-mammar}^  region,  and  in  pronounced  cases  may  produce  a 
deep  horizontal  furrow  across  the  base  of  the  chest  at  the  level  of  the  en- 
siform  cartilage.  If  the  retraction  is  limited  to  this  part,  it  indicates  in 
most  cases  a  catarrh  of  the  inferior  lobes  of  the  lungs,  which  are  insuffi- 
ciently filled  with  air  ;  but  if  the  ribs  are  very  soft  from  rickets,  the  de- 
pression may  be  noticed  in  ordinary  respiration  although  the  lungs  are 
sound.  Sometimes  the  soft  parts  of  the  chest  also  sink  in.  The  intercos- 
tal spaces  are  hollowed  ;  the  suprasternal  notch  and  supraclavicular  spaces 


EXAMINATION   OF   THE   CHEST — PALPATION.  401 

are  excavated ;  and  if  the  dyspnoea  reach  an  extreme  degree,  the  lower 
half  of  the  sternum  with  its  attached  cartilages  is  depressed  into  a  deep  pit 
at  each  inspiratory  movement.  When  the  retraction  is  thus  pronounced, 
there  is  usually  an  impediment  at  the  upper  part  of  the  trachea.  Ketrac- 
tion  to  this  degree  is  seen  in  membranous  and  stridulous  laryngitis,  in 
narrowing  of  the  glottis  from  any  cause,  and  in  cases  of  lodgement  of  a 
foreign  substance  in  the  upper  part  of  the  windpipe.  Still,  even  in  some 
cases  of  pleurisy  with  effusion,  marked  retraction  is  seen  on  both  sides  of 
the  chest  although  the  impediment  to  full  inspiration  only  affects  one 
lung. 

Enlargement  of  one  side  of  the  chest  can  sometimes  be  detected  by  the 
eye  ;  but  it  is  more  accurately  estimated  by  the  cyrtometer.'  A  tracing 
made  from  this  instrument  upon  paper  shows  immediately  if  one  side  of 
the  chest  be  larger  than  the  other.  A  characteristic  sign  of  pleuritic  effu- 
sion is  dilatation  and  squareness  of  outline  of  the  affected  side. 

Unilateral  shrinking,  from  fibroid  induration,  or  old  pleurisy  with  firm 
adhesions,  may  be  also  readily  estimated  by  the  same  means. 

Deficiency  of  movement  of  the  chest  is  sometimes  better  appreciated 
by  the  hand  than  by  the  eye.  The  hand  also  detects  vibration  of  the  chest- 
wall,  if  this  be  present.  In  children,  however,  there  is  seldom  a  normal 
fremitus  when  the  child  speaks  or  cries  ;  for  in  the  high-pitched  notes 
which  alone  escape  from  the  childish  larynx  the  vibrations  succeed  one 
another  too  rapidly  to  be  readily  perceptible  by  the  hand.  Consequently, 
unilateral  absence  of  this  sign,  which  in  the  adult  is  an  important  means 
of  distinguishmg  between  consolidation  of  the  lung  and  liquid  effusion  in 
the  pleura,  fails  us  in  the  case  of  young  patients.  Even  when  detected, 
vocal  fremitus  furnishes  no  certain  indication.  If  present  on  the  sound 
side,  it  may  be  felt  strongly  over  a  hquid  effusion,  for  the  vibration  is 
readily  conducted  by  the  thoracic  wall  from  one  side  of  the  chest  to  the 
other.  I  have  known  it  to  be  felt  strongly  on  the  affected  side  in  a  case 
of  recent  absorption  of  pleuritic  fluid,  although  almost  absent  on  the  sound 
half  of  the  chest ;  and  again,  in  a  case  of  apparently  exactly  similar  kind  it 
has  been  completely  absent  over  the  seat  of  disease,  although  present  else- 
where. 

A  rhonchal  or  friction  fremitus  is  much  more  common  than  a  vocal 
vibration  in  the  young  subject,  but  the  sign  is  of  little  value.  Fluctuation 
can  sometimes  be  discovered  in  the  interspaces  in  cases  of  pleuritic  effusion 
and  is  a  valuable  sign  of  the  presence  of  fluid.  To  detect  it,  a  finger  of 
each  hand  should  be  jDlaced  at  the  two  extremities  of  the  same  interspace. 
The  impulse  of  a  gentle  tap  is  then  often  conducted  distinctly  through  the 
fluid  from  one  finger  to  the  other. 

The  exact  site  of  the  apex-beat  of  the  heart  should  be  always  ascer- 
tained, as  this  may  be  greatly  influenced  by  disease  in  the  chest  cavity.  In 
young  children  and  infants  the  normal  position  of  the  heart's  apex  is 
nearer  to  the  left  nipjale  than  is  the  case  in  the  adult.  This  is  partly 
due  to  the  position  of  the  nipple,  which  is  placed  relatively  lower  than  it  is 
in  later  life.  In  many  children,  instead  of  lying  over  the  fourth  rib  it  is  in 
the  fourth  interspace  or  on  the  upper  border  of  the  fifth  rib.  But  in  addi- 
tion to  the  lower  position  of  the  nipple,  the  heart  itself  is  relatively  smaller 
or  seems  to  lie  higher  in  children,  especially  during  the  period  of  infancy. 


^  A  perfectly  efficient  cyrtometer  may  be  made  by  taking  two  pieces  of  soft  metal,, 
without  resilience,  suck  as  composition  gas-tubing,  drawn  out  to  one-eighth  of  an  inch„ 
and  uniting  them  by  a  piece  of  caoutchouc  tubing. 

26 


402  DISEASE  IN   CHILDREN. 

Often  the  apex  will  be  found  to  beat  in  the  fourth  interspace,  exactly  on 
the  site  of  the  nipple. 

Diseases  of  the  heart-walls  of  course  influence  considerably  the  position 
of  the  apex-beat ;  but  when  the  organ  is  healthy,  the  position  of  its  apex 
may  be  altered  by  morbid  conditions  in  neighbom-ing  parts.  Effusion  into 
the  chest  cavity  causes  displacement  of  the  heart's  apex.  According  to  the 
side  affected  the  heart  may  be  pushed  considerably  to  the  right  or  to  the 
left.  In  cases  of  left  pleurisy  with  copious  effusion  it  is  not  uncommon  to 
find  the  aj)ex-beat  of  the  heart  in  the  epigastrium,  and  sometimes  the  im- 
pulse can  be  felt  to  the  right  of  the  sternum.  Cardiac  clisjolacement  does 
not,  however,  always  result  fi'om  effusion  into  the  pleura ;  and  therefore  its 
absence  must  not  be  taken  to  indicate  that  the  physical  signs  are  capable 
of  another  interpretation.  If  adhesions  have  formed  between  the  pericar- 
dium and  the  left  pleura,  the  heart  is  held  in  place  and  cannot  be  jDushed 
aside  by  the  effusion.  The  position  of  the  heart  may  be  also  altered  by 
contraction  of  the  lung  on  one  side,  but  in  this  case  the  heart  is  drawn 
towards  the  affected  part.  In  fibroid  induration  of  the  lung,  disease  on  the 
right  side  moves  the  heart  to  the  right ;  disease  on  the  left  side  draws  the 
organ  upwards  and  to  the  left.^ 

Besides  the  position  of  the  heart  the  exact  level  of  the  liver  and  spleen 
should  be  noted,  as  the  position  of  these  organs  may  help  us  to  a  conclu- 
sion in  a  doubtful  case.  These  viscera  are  often  sensibly  displaced  by  the 
pressure  of  a  liquid  effusion  in  the  chest,  while  displacement  of  the  liver 
by  the  bulging  of  a  croupous  pneumonia  is  so  rare  as  to  be  a  clinical  curi- 
osity. If  the  lung  be  contracted,  the  liver  or  spleen  is  drawn  upwards 
into  the  chest. 

Percussion  of  the  chest  in  the  infant  and  young  child  should  be  con- 
ducted with  deliberation.  If  care  be  taken  that  the  hands  are  perfectly 
warm,  and  that  undue  violence  is  avoided,  the  j)rocess  seldom  arouses  any 
special  opposition.  It  is  sometimes  recommended  to  reverse  the  ordinary 
arrangement  and  practise  auscultation  before  employing  percussion,  but 
this  inversion  of  the  customary  rule  is  at  least  unnecessary. 

In  the  young  subject,  except  perhaps  in  the  new-born  infant,  the  re- 
sonance of  the  chest  is  greater  than  it  is  in  after-hfe  ;  and  the  percussion 
note  obtained  over  an  area  of  consohdation  is  often  so  modified  by  reson- 
ance from  healthy  tissue  aroimd  that  dulness  is  only  imperfectly  marked 
and  may  escape  the  notice  of  an  unpractised  ear.  Percussion  should  be 
mediate  ;  and  it  is  advisable  always  to  use  two  fingers  in  striking  the  fin- 
g'er  placed  upon  the  chest- wall.  By  this  means,  without  employing  undue 
force,  a  larger  body  of  sound  is  elicited  than  if  the  chest  is  struck  with  one 
finger  only,  and  dulness,  if  present,  can  be  more  readily  ap2:)reciated.  As 
we  proceed  we  must  be  careful  to  make  constant  comparison  between  dif- 
ferent parts  of  the  chest — between  opposite  sides,  between  the  base  and  the 
apex,  etc.  To  make  the  comparison  an  accurate  one  the  same  period  of 
the  respiratory  movement  should  be  chosen  for  striking  upon  the  finger  ; 
for  if  one  part  of  the  chest  be  percussed  at  the  end  of  an  inspiration,  and 
another  at  the  end  of  an  expiration,  the  diflerence  even  in  a  healthy  chest 
may  be  considerable.  When  the  consolidation  consists  in  scattered  no- 
dules, as  in  the  beginning  of  catarrhal  pneumonia  or  in  lobular  collapse, 
dulness,  which  escapes  the  ear  when  percussion  is  made  in  the  ordinary 
manner  may  often  be  detected  by  using  "  broad  percussion,"  i.e.,  by  strik- 

'  Displacement  in  the  same  direction  (upwards  and  to  the  left)  may  be  a  consequence 
of  enlargement  of  abdominal  organs  or  distention  of  the  peritoneal  cavity  by  fluid. 


EXAMINATION   OF   THE   CHEST — PEKCUSSION.  403 

iug  with,  three  fingers  upon  three  fingers  placed  upon  the  chest-wall  as  plex- 
imeters.  By  this  means  the  sound  is  collected  from  a  larger  ai-ea  of  lung- 
tissue  than  if  one  finger  only  were  employed. 

But  besides  the  character  of  the  sound  elicited  in  percussion,  it  is  im- 
portant to  attend  to  the  degree  of  resistance  of  the  chest-wall.  The  resist- 
ance to  the  percussing  finger  varies  greatly  in  different  cases  and  is  a  sign 
of  no  little  importance.  In  the  consolidation  of  pneumonia  and  in  that 
of  pulmonary  atelectasis,  when  the  collapse  occupies  only  a  superficial  layer 
of  tissue,  resistance  is  slight.  In  more  extensive  collapse,  as  when  the  con- 
densed tissue  embraces  an  entire  lobe,  and  in  fibroid  induration  of  the 
lung,  the  resistance  is  greater  ;  but  the  maximum  of  resistance  is  reached 
in  cases  of  cirrhosis  of  the  lung,  with  superadded  catarrhal  pneumonia,  and 
in  pleuritic  effusion.  The  resistance  is  here  extreme,  and  the  sensation 
conveyed  to  the  finger  is  that  of  percussing  a  thick  block  of  wood.  It  is 
very  important  to  educate  the  sense  of  touch  so  as  readily  to  aj)preciate 
the  several  degrees  of  resistance,  as  this  faculty  is  a  great  addition  to  our 
resources  in  the  matter  of  diagnosis. 

In  percussing  the  supra-spinous  fossae  it  is  very  necessary  to  see  that 
the  muscles  of  the  shoulders  are  equally  relaxed  on  both  sides.  Elevation 
of  the  shoulder,  or  a  cramped  position  contracting  the  muscles  of  one  side, 
will  modify  the  percussion  note  and  make  the  sound  more  or  less  dull,  al- 
though the  lung  is  perfectly  healthy.  If  an  infant  be  placed  in  his  nurse's 
arms  in  the  position  already  described,  and  an  older  child  be  made  to  sit 
with  arms  folded,  shoulders  depressed,  and  back  slightly  bowed,  the  re- 
sults of  percussion  may  be  depended  upon.  Too  much  stress  should  not 
be  laid  upon  slight  differences  between  the  two  sides.  A  temporary  col- 
lapse of  the  air-cells  at  the  apex  is  not  uncommon  from  imperfect  expan- 
sion of  this  part  of  the  lung,  and  therefore  slight  dulness  noticed  at  one 
visit  may  on  the  next  have  completely  disappeared.  There  is  also  a  spe- 
cial source  of  error  in  percussing  the  posterior  bases  of  the  lungs  in  chil- 
dren which  it  is  important  to  be  aware  of.  In  young  subjects  the  liver  is 
relatively  large,  and  rises  higher  on  the  right  side  of  the  chest  than  it  does 
in  older  persons.  There  is  therefore  normally  a  certain  dulness  of  percus- 
sion in  the  right  infra-scapular  region.  This  dulness  is  more  extensive  in 
some  healthy  children  than  it  is  in  others.  We  may  recognise  the  cause 
of  the  modified  note  by  remarking  that  the  breath-sounds  at  this  point, 
although  weak,  are  perfectly  healthy. 

Special  varieties  of  the  percussion  note  have  little  oi"  no  diagnostic 
value  in  young  subjects.  The  tubular  (or  tracheal)  note  is  often  obtained 
in  various  states  of  the  lung-tissue,  and  is  not  characteristic  of  any  special 
condition.  The  "cracked-jar"  note  is  a  natural  phenomenon  in  early  life 
if  the  yielding  chest  be  percussed  during  expiration  or  when  the  mouth  is 
open. 

In  auscultation  of  the  chest,  however  young  the  child,  the  stethoscope 
should  always  be  used.  This  instrument  is  even  of  greater  value  in  the 
young  subject  than  it  is  in  the  adult,  for  the  chest  being  smaller,  it  is  more 
important  to  limit  as  narrowly  as  possible  the  area  under  investigation, 
I  have  rarely  known  children  object  to  its  employment  if  the  instrument 
had  been  first  placed  in  their  hands  and  spoken  of  as  "a  trumpet." 
Indeed,  the  use  of  this  familiar  word  usually  awakens  their  interest  and 
actually  facihtates  the  examination. 

In  the  normal  state  the  breath-sounds  are  coarser  and  harsher  (puerile 
respiration)  than  they  become  in  older  persons,  and  this  harshness  in  cer- 
tain patients  is  so  pronounced  that  it  is  not  unfrequently  mistaken  by  an 


404  DISEASE   IX   CHILDEElSr, 

inexperienced  observer  for  a  sign  of  disease.  The  harsli  character  of  the 
breath-sound  is  especially  marked  at  the  apices,  and  the  expiration  at  this 
part  of  the  lung  is  often  j^rolonged  without  the  peculiarity  being  an  abnor- 
mal phenomenon.  Conduction  of  sounds  from  the  pharj-nx  and  trachea 
to  the  apices  is  especially  common,  and  it  is  not  rare  to  find  the  respu'a- 
tion  at  the  supra-spinous  fossae  curiousty  loud  and  hollow  or  blowing, 
although  the  lungs  are  healthy.  This  hollow  breathing  is  no  doubt  con- 
ducted from  the  throat.  It  is  often  a  sign  of  enlargement  of  the  bron- 
chial glands,  these  bodies  forming  a  medium  of  communication  between 
the  windpipe  and  the  wall  of  the  chest.  It  may  be  heard,  however,  in 
cases  of  enlarged  tonsils,  and  is  sometimes  present,  while  the  mouth  is 
closed,  in  childi-en  in  whom  no  other  morbid  condition  of  any  kind  can  be 
discovered.  In  such  cases  it  is  greatly  modified  in  character  when  the 
mouth  is  open.  The  source  of  this  variety  of  blowing  breathing  can 
usually  be  detected  by  noticing  that  it  is  heard  equally  j)lainly  at  both 
apices,  is  chiefly  marked  in  exphation,  and  is  accompanied  by  no  rhonchal 
sound  or  any  dulness  of  the  percussion  note. 

Weakness  of  the  vesicular  murmur  is  much  less  common  as  a  normal 
condition  than  loudness  of  the  breath-sound.  It  is,  however,  present  in 
some  children  as  an  individiial  pecuharity.  If  general  over  both  sides,  it 
is  a  sign  of  no  importance.  If  hmited  to  j)articular  spots,  it  is  of  greater 
moment,  and  when  noticed  at  the  base  of  one  side  should  not  be  disre- 
garded. It  may  be  an  early  sign  of  pleurisy  or  may  indicate  collajose. 
At  the  apices  it  often  arises  fi'om  insufficient  expansion  of  lung-tissue, 
and  may  be  of  trifling  consequence.  In  such  a  case  it  usually  passes  off 
quickly,  and  at  the  next  examination  may  no  longer  be  detected. 

The  readiness  with  which  sounds  are  conveyed  from  one  part  of  the 
chest  to  another  is  a  common  source  of  error.  Thus,  sounds  generated  at 
the  base  of  one  lung  may  often  be  plainly  heard  at  the  corresjDonding  part 
of  the  other  and  healthy  lung.  In  cases  of  dilated  bronchus  from  fibroid 
induration  it  is  not  uncommon  to  find  cavernous  breathing  with  metallic 
gurgling  rhonchus  at  both  posterior  bases — on  the  sound  as  well  as  on  the 
affected  side.  So,  also,  a  subcrepitant  rale  developed  in  one  lung  may 
be  plainly  heard  on  the  opjDosite  side,  perhaps  over  the  site  of  a  loculated 
pleurisy  or  collapsed  lobe,  and  give  rise  to  much  perplexity.  In  these  cases 
the  origin  of  the  transmitted  sound  can  usually  be  detected  by  noticing 
that  the  qualit}^  and  pitch  of  the  conducted  breath-sound  or  rale  are  exactly 
that  heard  on  the  affected  half  of  the  chest,  only  diminished  in  intensity; 
the  sound  is  identical  in  character  but  weaker  in  force.  This  is  rarely  if 
ever  the  case  with  soimds  generated  spontaneously  in  tAvo  different  spots. 

Bronchial,  blowing  and  cavernous  breath-sounds  are  produced  in  chil- 
dren by  the  same  mechanism  which  gives  rise  to  them  in  the  adult,  and 
correspond  to  much  the  same  conditions.  In  the  child,  however,  pecuhar- 
ities  in  this  respect  are  sometimes  noticed.  The  morbid  quahty  conferred 
upon  the  breath-sound  is  often  a  step  in  advance  of  that  heard  under 
similar  conditions  in  the  adult.  Thus,  cavernous  breathing  is  more  often 
a  sign  of  mere  solidification  of  tissue,  and  is  frequently  present  when  the 
lung  is  compressed  by  pleuritic  effusion.  So,  also,  the  amphoric  breath- 
sound  with  tinkling  resonance  of  the  voice  or  cough  is  almost  always  the 
consequence  of  a  large  cavity  or  great  dilatation  of  a  bronchus.  It  is  heard 
in  cases  of  phthisis,  of  cirrhosis  of  the  lung,  or  of  subacute  catarrhal 
pneumonia.  Pneumothorax,  to  which  cause  it  is  almost  solely  owing  in 
the  adult,  is  a  very  rare  condition  in  the  child,  and  the  morbid  sign  can 
seldom  be  attributed  to  this  cause. 


EXAMIlSrATIOlSr  OF   THE   CHEST — ATJSCUITATIOIir.  405 

Althougli  the  auscultatory  sounds  are  frequently  magnified  in  the 
child,  it  sometimes  happens  that  the  contrary  condition  is  found.  A  patch 
of  consolidation,  if  covered  by  a  layer  of  healthy  lung-tissue,  may  give  rise 
to  no  dulness  or  alteration  of  breath-sound,  and  a  bronchophonic  reson- 
ance of  the  voice  and  cry  may  be  the  only  sign  which  betrays  its  existence. 
In  crying  infants  the  intensified  vocal  resonance  is  an  important  test  of 
consohdation.  If  the  resonance  have  an  segophonic  quahty  it  is  character- 
istic of  moderate  effusion. 

The  examination  of  the  chest  should  always  be  as  complete  as  possible. 
It  is  not  enough  merely  to  examine  the  posterior  part  of  the  thorax,  trust- 
ing that  if  this  be  healthy  the  anterior  part  is  healthy  too.  A  patch  of 
croupous  pneumonia  or  a  loculated  pleurisy  may  occupy  any  part  of  the 
lung  or  chest  cavity.  Either  may  be  confined  to  the  apex,  may  he  under 
one  arm,  or  may  be  found  seated  anteriorly  or  laterally  as  well  as  behind. 
If,  therefore  the  front  of  the  chest  is  left  unnoticed,  we  may  overlook  dis- 
ease which  closer  examination  would  have  discovered.  Even  if  the  child 
cry  during  the  ojDeration,  much  may  still  be  learned.  The  cry  usually 
ceases  each  time  the  breath  is  taken  in,  so  that  inspiration  is  audible.  Its 
quality  can  therefore  be  ascertained  at  this  time.  Moreover,  as  the  chest 
is  expanded  deeply  after  a  prolonged  crying  expiration,  the  air-cells  are 
fully  inflated  and  few  adventitious  sounds  can  escape  oui'  notice. 


CHAPTEE  11. 

LARYNGITIS. 

Inflammation  of  the  larynx  is  a  not  uncommon  affection  in  childliood. 
The  disease  may  occur  as  a  simple  catarrh  of  the  lai7nx  or  as  a  more  se- 
vere inflammation  resulting  from  a  burn  or  scald.  In  these  cases  it  is  of 
course  a  primary  lesion.  It  may  also  occur  secondarily  as  a  consequence 
of  a  constitutional  disease,  such  as  tubercle  or  syphilis.  There  is  a  special 
form  of  the  primary  affection  which  is  accompanied  by  sjDasm  and  is  pe- 
culiar to  early  hfe.  This  complaint  is  often  confounded  vvith  membranous 
croup,  and  is  the  "  catarrhal  croup  "  of  the  older  writers.  It  is  seldom  a 
fatal  disease,  although  it  produces  very  alarming  symptoms.  In  the  pres- 
ent chapter  thi^ee  varieties  of  laryngitis  will  be  described,  viz.,  simple 
laryngitis,  stridulous  laryngitis,  and  tubercular  laryngitis.  The  lesions 
which  aflfect  the  larynx  in  cases  of  inherited  syphiHs  are  referred  to  else- 
where (see  page  204). 

SIMPLE  LARYNGITIS. 

Causation. — On  account  of  the  sensitiveness  of  scrofulous  children  ta 
changes  of  temperature  and  theii-  Hability  to  catarrh,  laryngitis  is  more 
common  in  them  than  it  is  in  others  who  are  free  from  this  unfortunate  dis- 
position. In  some  the  larynx  seems  to  have  a  special  proneness  to  suffer 
in  the  cold  or  changeable  seasons  of  the  year.  No  period  of  childhood  is 
exempt  from  laryngeal  catarrh,  for  although  the  disorder  is  more  often 
seen  in  children  over  six  years  old,  it  may  be  met  with  as  early  as  the  end 
of  infancy.  In  infancy,  however,  the  complaint  in  the  simple  form  is  com- 
paratively rare.  At  this  period  laryngitis  is  commonly  the  consequence  of 
a  syphilitic  taint.  Amongst  the  children  of  the  poor  severe  laryngitis  from 
burns  and  scalds  is  sometimes  met  with.  This  form  of  the  disea,se  is  al- 
most confined  to  children  between  two  and  three  years  old,  and  is  due  to 
an  attempt  to  drink  water  from  the  spout  of  a  kettle  as  this  stands  sirn- 
mering  by  the  side  of  the  fire.  A  violent  inflammation  results  from  this 
accident  and  may  quickly  end  in  death.  An  equally  severe  laryngitis  with 
oedema  of  the  glottis  is  sometimes  met  with  as  a  secondary  affection  follow- 
ing serious  acute  disease.  It  may  occur  as  a  sequel  of  small-pox,_  erysipelas, 
or  typhoid  fever.  (Edema  of  the  glottis  without  inflammation  is  also 
sometimes  a  symptom  of  acute  Bright's  disease. 

Chronic  laryngitis  is  less  common  than  the  acute  variety,  but  some 
times  occurs  in  weakly  children  as  the  result  of  an  acute  attack.  It  may 
foUow  measles  or  membranous  croup,  and  is  apt  to  prove  obstinate. 

Morbid  Anatomy. — The  mucous  membrane  and  submucous  tissue  be- 
come congested  and  oedematous,  and  their  colour  is  redder  than  in  health. 
In  cases  of  simple  laryngitis  the  change  is  probably  confined  to  the  epi- 
glottis and  ary-epigiottidean  folds,  leaving  the  true  vocal  cords  unaltered. 


LAEYISTGITIS — MORBID   AISTATOMY — SYMPTOMS.  407 

Some  thick  mucous  is  secreted.  Ulceration  is  very  rare  in  early  life,  and 
probably  never  occurs  in  the  primary  form  of  the  disease. 

In  the  severe  laryngitis  which  is  the  result  of  a  scald  the  soft  palate 
and  fauces  are  white  and  swollen  ;  and  the  epiglottis  and  parts  around  are 
thickened  and  congested.  A  so-called  false  membrane  often  forms  upon 
the  surface.  This  to  the  eye  appears  to  be  identical  with  the  false  mem- 
brane of  diphtheria,  but  is  said  to  differ  from  it  in  its  microscopical  char- 
acters. It  is  probably,  as  Dr.  Wallace  long  ago  suggested,  the  natural 
epithelial  layer  altered  in  structure. 

Symptoms. — In  the  mild  form  the  child  is  hoarse  and  soon  loses  his 
voice  more  or  less  completely.  His  cough  is  hoarse  and  infrequent ; 
sometimes  it  occurs  in  paroxysms.  There  is  little  or  no  fever,  and  the 
breathing  is  not  interfered  with.  If  the  hoarseness  do  not  proceed  to  ac- 
tual aphonia,  it  is  often  more  marked  in  the  evening.  The  cough,  too,  is 
generally  worse  at  night  when  the  child  goes  to  bed.  The  hoarseness  of 
the  voice  may  be  only  noticed  when  the  child  is  crying.  If  the  patient  be 
kept  in  a  suitable  temperature,  the  sj'mptoms  of  catarrh  subside  after  a 
few  days,  and  seldom  last  longer  than  a  week.  If  the  indisposition  is 
lightly  treated,  and  measures  are  not  taken  to  protect  the  child  from  fur- 
ther exposure,  the  complaint  may  become  more  serious  and  may  be  com- 
plicated with  spasm  (stridulous  laryngitis). 

The  mor^e  semre  variety  is  well  illustrated  by  cases  of  scald  or  burn  of 
the  larynx,  although,  as  has  been  said,  the  affection  is  sometimes  due  to 
other  causes. 

Immediately  after  the  scald  the  child  complains  of  pain  in  the  throat, 
and  this  part  on  inspection  is  seen  to  look  white  and  shrivelled ;  but  there 
is  at  first  no  difficulty  of  breathing  and  the  laiynx  seems  to  have  escaped. 
The  patient  screams  violently  and  wiU  not  attempt  to  swallow ;  but  after  a 
time  the  immediate  effects  of  the  accident  appear  to  pass  off,  and  when  put 
to  bed  the  child  falls  quietly  asleep.  After  a  few  hours,  however,  usually 
from  three  to  six,  his  breathing  is  noticed  to  be  noisy  and  whistHng. 
Laryngitis  has  now  begun.  The  respirations  become  laboured  and  rapid  ; 
the  face  is  pale  and  tinted  with  lividity  about  the  eyehds  and  mouth  ;  the 
pulse  is  smaU  and  feeble  ;  the  skin  is  cool ;  the  extremities  are  cold  ;  and 
the  child  is  drowsy,  although  he  can  be  roused  with  difficulty.  If  at  this 
stage  the  finger  be  passed  into  the  back  of  the  fauces,  the  epiglottis  will 
be  felt  hard  and  swollen  to  the  shape  of  a  gooseberry  or  small  marble. 
There  is  recession  of  the  soft  parts  of  the  chest  in  inspiration,  and  an 
examination  detects  sonorous  and  sibilant  rales  all  over  the  lungs.  There 
is  no  dulness  on  percussion. 

After  a  few  hours  all  the  symptoms  become  aggravated.  The  breathing- 
is  more  and  more  laboured  and  "croupy,"  the  larynx  rises  and  falls  rapidly, 
and  at  each  inspiration  the  soft  parts  of  the  chest — the  intercostal  spaces, 
supra-clavicular  fossae,  and  the  epigastrium — sink  deeply  in.  The  child 
lies  with  his  head  retracted,  his  face  swollen  and  livid,  his  eyes  injected, 
his  nares  acting,  and  his  mouth  open,  making  convulsive  gasps  for  breath. 
His  extremities  are  cold,  and  his  pulse  is  often  too  frequent  and  feeble  to 
be  counted.  Although  only  half  conscious  the  child  is  much  agitated, 
tossing  his  arms  about  and  showing  signs  of  the  greatest  distress.  Per- 
cussion of  the  back  usually  detects  some  want  of  resonance,  and  much 
large  bubbling  is  heard  in  the  air-tubes.  Sometimes  there  is  local  dulness 
from  collapse  of  lung.  In  this  state  the  child  may  sink  and  die  slowly,  or 
expire  more  suddenly  in  a  convulsive  fit. 

The  above  is  an  aggravated  case,  but  unfortunately  far  from  an  uncom- 


408  DISEASE   IN   CHILDEEIS'. 

mon  one.  Death  may  occur  as  early  as  twenty-foui'  hoiu's  after  the  acci- 
dent. The  end  is  not,  however,  always  reached  so  rapidly.  The  child 
may  linger  for  two,  thi-ee,  or  four  days  before  he  finally  sinks  ;  or  life  may 
be  prolonged  to  the  end  of  the  week.  The  duration  depends  in  great 
measure  upon  the  degree  of  interference  with  respiration  and  the  patient's 
capacity  for  taking  nourishment.  If  the  oedema  of  the  glottis  be  less  com- 
plete, the  breathing  after  being  laboured  and  stridulous  for  twenty-four  or 
forty-eight  hours,  with  signs  of  deficient  aeration  of  the  blood,  may  become 
easier,  and  then  gradually  retui'n  to  a  normal  state.  The  Toice  is  very 
hoarse  and  the  cough  "  croupy."  In  these  cases  the  dyspnoea  varies  in 
degree  from  time  to  time,  being  subject  to  occasional  increase  when  the 
child  is  distressed  or  made  to  swallow.  After  the  cessation  of  the  more 
urgent  symptoms  the  voice  may  remain  hoarse  and  the  cough  be  occasion- 
aUy  "  croupy  "  for  some  days. 

A  little  boy,  aged  four  months,  was  brought  to  the  East  London  Chil- 
dren's Hospital  at  one  p.m.  On  the  previous  night  the  bed  on  which  he 
was  Ijing  had  caught  fire,  and  the  child,  who  had  been  placed  on  a  water- 
proof cloth,  was  surrounded  with  flame  and  smoke.  Happdy  he  was 
quickly  rescued,  although  not  before  the  palliasse  had  been  nearly  destroyed. 
"When  taken  out  his  body  was  blackened  with  the  smoke.  Soon  afterwards 
his  breathing  became  difficult,  and  at  times  the  mother  thought  he  would 
be  suffocated." 

On  admission  the  skin  of  the  arms  was  seen  to  be  tinted  brown  from  the 
action  of  the  heated  au-,  but  there  was  no  external  sign  of  burn.  The 
infant's  breathing  was  laboured,  and  his  cry  hoarse  and  weak.  At  each 
inspiration  the  soft  parts  of  the  chest  receded  deep)ly.  The  face  was  dusky, 
the  nares  acted  strongly,  and  the  external  jugulars  and  superficial  veins 
generally  were  unusually  Visible.  The  fauces  looked  red  and  swollen. 
Temperature,  98° ;  pulse,  160 ;  respu'ations,  72.  In  the  evening  the  tem- 
perature rose  to  103°;  pulse,  140;  respirations,  80.  The  child  slept  fairly 
well  in  the  night,  and  in  the  morning  expectorated  a  piece  of  membrane 
one  inch  in  length  and  a  quarter  of  an  inch  broad.  It  had  the  ordinary 
naked-eye  appearance  of  false  membrane.  The  next  day  the  breathing  was 
easier  and  the  h'sidity  of  the  face  less.  Two  days  afterwards  signs  of 
pneumonia  were  discovered  at  the  left  back  ;  but  this  disease  ran  a  favour- 
able course,  and  in  about  ten  days  from  the  time  of  the  accident  the  child 
was  convalescent.  He  never  had  any  difficulty  in  swallowing.  He  was 
treated  with  hot  Iraseed-meal  poultices  and  a  saline  mixture  containing 
small  doses  of  antimonial  vdne. 

In  cases  such  as  these,  if  tracheotomy  has  to  be  performed  on  account 
of  the  intensity  of  the  dyspnoea,  the  patient  often  dies  from  a  secondary 
inflammation  of  the  lung.  The  ordinary  non-traumatic  laryngitis  in  the 
child,  if  at  all  severe,  is  also  usually  associated  with  bronchitis,  j)neumonia, 
or  pleurisy. 

The  chronic  form  of  larjmgitis  is  sometimes  seen  in  connection  with 
folhcular  pharyngitis.  It  is  indicated  by  an  altered  quality  of  the  voice, 
which  becomes  thick  and  veiled,  and  is  sometimes  quite  hoarse  in  the  even- 
ing. There  is  also  a  hard  cough,  which  may  be  paroxysmal,  and  is  often 
accompanied  by  pain  shooting  up  into  the  sides  of  the  head  or  the  ears. 
I  have  occasionally  met  with  a  simple  chronic  larj-ngitis  unconnected  with 
any  abnormal  state  of  the  fauces,  and  ajDparently  not  the  consequence  of  a 
constitutional  cachexia.  One  such  case,  occurring  in  a  child  aged  one  year 
and  eleven  months,  vnll  be  afterwards  refeiTed  to. 

Diagnosis. — The  simple    form  of  the  disease,  where    there  is  much 


LARYNGITIS — DIAGNOSIS.  409 

Jioarseness  of  the  voice  and  cry,  a  thick  cough,  and  some  redness  of  the 
fauces,  without  fever,  or  with  only  moderate  pyrexia,  cannot  be  mistaken. 
If  the  symptoms  become  more  \irgent,  and  there  is  laboured  breathing, 
pneumonia  and  bronchitis  may  be  excluded  by  the  absence  of  the  charac- 
teristic physical  signs  about  the  lungs,  and  the  normal  or  only  slightly 
elevated  temperature.  Still,  it  must  be  remembered  that  these  cases, 
whether  due  or  not  to  a  traumatic  cause,  are  often  complicated  by  acute 
chest  disease. 

In  the  case  of  scald  of  the  larjmx,  the  history  will  usually  be  sufficient 
to  decide  the  nature  of  the  illness.  It  must  not  be  forgotten  that  in  this 
variety  of  laryngitis  the  symptoms  seldom  come  on  directly  after  the  acci- 
dent, but  that  there  is  almost  invariably  an  interval  of  some  hours  before 
the  signs  of  dysjwioea  begin  to  be  noticed.  In  every  such  case,  then,  we 
must  be  on  our  guard,  and  must  not  conclude  that  all  danger  has  passed 
because  the  child  apjDcars  at  first  to  have  escaped  serious  injury. 

In  epidemics  of  diphtheria  a  slight  scald  of  the  larynx  may  predispose 
a  child  to  fall  a  victim  to  the  zymotic  disease.  Mr.  Parker  has  pubhshed 
the  case  of  a  Kttle  girl,  aged  three  years,  in  whom  "  croupy  "  symptoms 
came  on  three  days  after  an  apparently  trifling  scald  of  the  throat,  and  in 
spite  of  tracheotomy  the  patient  died  on  the  sixth  day  of  the  illness.  On 
examination  of  the  air-passages,  the  epiglottis  and  ary-epiglottidean  folds 
were  covered  with  membrane  ;  the  tracheal  mucous  membrane  was  in- 
tensely injected  and  coarsely  granular  in  appearance,  and  this  condition 
was  seen  to  extend  as  far  as  the  tertiary  bronchi.  Pieces  of  thinnish,  red, 
well-formed  membrane  were  also  found  on  the  pharynx  and  in  some  of  the 
tubes.  In  this  case  the  illness  came  on  at  too  late  a  period  after  the  acci- 
dent to  be  fau-ly  attributable  to  the  scald  ;  the  symptoms  were  those  of 
laryngeal  diphtheria,  and  the  anatomical  characters  were  indicative  of  a 
specific  and  not  of  a  simple  inflammation  of  the  larynx  and  trachea. 

In  all  cases  of  chronic  hoarseness  it  is  as  important  in  the  child  as  it  is 
in  the  adult  to  use  the  laryngoscope  wherever  practicable.  Children,  un- 
fortunately, are  usually  troublesome  subjects  for  this  method  of  investi- 
gation ;  but  if  Ihe  child  is  old  enough  to  understand  the  object  of  the  ex- 
amination, we  can  often,  by  perseverance  and  by  making  him  suck  lumps 
of  ice  before  the  instrument  is  applied,  succeed  in  getting  a  view  of  the 
vocal  cords,  By  this  means  we  can  sometimes  exclude  the  presence  of 
chronic  inflammation  and  obtain  a  valuable  hint  for  treatment.  It  must 
be  remembered  that  hoarseness  may  be  the  consequence  of  the  imperfect 
approximation  of  the  vocal  cords.  Dr.  Vivian  Poore  has  referred  to  the 
oase  of  a  little  boy  who  had  been  long  under  treatment  for  laryngitis.  In 
this  case  the  hoarseness  was  found  by  the  laryngoscope  to  be  due  to  exces- 
sive anaemia  of  the  larynx,  with  failure  in  the  power  of  the  adductors  ;  and 
fresh  air,  good  diet,  and  iron  soon  restored  the  lad  to  health. 

Chronic  laryngitis  must  not  be  confounded  with  the  alteration  of  voice 
which  occurs  as  a  consequence  of  enlarged  and  caseous  bronchial  glands. 
In  that  disease  hoarseness  is  a  late  symptom,  and  does  not  appear  until 
general  pressure  signs  have  been  developed  in  the  chest  (see  page  182). 

Sometimes  hysterical  aphonia  is  found  in  girls.  It  is  distinguished 
from  chronic  laryngitis  by  the  history.  It  begins  quite  suddenly  and  is  at 
once  complete.     Equally  suddenly  it  subsides. 

A  girl,  between  eleven  and  twelve  years  old,  was  under  the  care  of  my 
colleague,  Dr.  Donkin,  in  the  East  London  Children's  Hospital,  The  pa- 
tient was  one  of  fifteen  children,  and  there  was  no  neurotic  tendency  in  the 
family.     One  child  had  died  of  croup,  and  the  girl  herself  had  had  a 


410  DISEASE   IN   CHILD RElSr. 

"  croupy  "  cough  up  to  the  age  of  seven  years.  She  was  of  healthy  appear- 
ance and  seemed  very  inteUigent.  Twelve  weeks  before  her  admission  she 
had  been  called  in  the  morning  and  had  answered  in  her  usual  voice ; 
but  when  she  was  dressed  it  was  found  that  she  had  complete  aphonia. 
Her  breathing  was  natural,  and  she  was  not  subject  to  attacks  of  dyspnoea. 
She  had  no  cough  or  soreness  of  the  throat,  but  there  seemed  to  be  some 
tenderness  at  the  angle  of  the  jaw.  Her  voice  was  quite  whispering,  but 
she  could  laugh  louder  than  she  could  talk.  She  did  not  appear  to  be 
troubled  by  her  infirmity,  but  was  anxious  to  get  well  on  account  of  her 
education. 

A  galvanic  current  was  applied  to  the  larjms.  The  girl  cried  loudly 
during  the  operation.  After  a  second  application  of  the  same  kind  the 
voice  suddenly  returned  ;  and  she  never  relapsed. 

Prognosis. — In  uncomplicated  cases  of  simple  laryngitis,  unless  the  in- 
flammation be  due  to  a  traumatic  cause,  the  child  almost  invariably  re- 
covers. In  the  traumatic  variety  the  prognosis  is  very  serious.  In  cases 
which  are  complicated  by  some  acute  lung  affection  the  prognosis  depends 
upon  the  pulmonary  rather  than  upon  the  laryngeal  complaint. 

Treatment. — In  ordinary  simple  laryngitis  the  child  should  be  kept  in 
an  equable  temperature  ;  his  throat  should  be  enveloped  in  cotton  wool  or 
a  cold-water  compress  ;  and  inhalation  should  be  prescribed  of  steam  im- 
pregnated with  tincture  of  benzoin  (a  teaspoonful  to  the  pint  of  boiling 
water).  The  bowels  should  be  relieved  by  a  mercurial  purge  ;  and  if  there 
be  much  oppression  of  breathing,  an  emetic  should  be  ordered  of  ipecacu- 
anha wine.  Afterwards,  a  saline  diaphoretic  can  be  given  containing  five 
or  ten  drops  of  antimonial  wine  to  the  dose.  A  mustard  foot-bath  is  also 
useful.  If  the  cough  is  troublesome  and  disturbs  the  rest,  smaU  doses  of 
paregoric  may  be  added  to  the  mixture. 

In  severe  cases,  where  the  dyspnoea  is  distressing,  a  blister  may  be  ap- 
plied to  the  neck  below  the  chin,  or  towards  the  top  of  the  sternum.  The 
child  should  be  placed  in  a  tent-bedstead,  as  in  diphtheria,  and  the  air 
around  the  patient  should  be  kept  moist  by  the  steam  boiler,  as  recom- 
mended for  that  disease.  The  general  treatment  will  depend  upon  the 
lung  affection,  which  in  these  cases  usually  complicates  the  laryngitis. 

In  the  violent  and  distressing  cases  which  result  from  a  scald  of  the 
glottis  energetic  treatment  is  required,  as  from  the  moment  when  the 
dyspnoea  becomes  lu-gent  the  life  of  the  child  is  in  the  greatest  danger. 
Dr.  Bevan,  of  Dublin,  after  considerable  experience  of  this  form  of  disease, 
powerfully  advocates  a  return  to  the  old  treatment  by  repeated  doses  of 
calomel.  He  states  that  if  this  plan  be  adopted,  immediate  relief  to  the 
symptoms  is  noticed  directly  green  stools  begin  to  be  passed,  showing 
that  the  system  is  under  the  influence  of  the  drug.  Dr.  Bevan  gives  a 
grain  of  the  salt  every  half  hour,  and  recommends  that  this  medication  be 
begun  directly  the  child  is  seen  after  the  accident,  without  waiting  for 
laryngeal  symptoms  to  declare  themselves.  He  greatly  prefers  this  method 
of  treatment  to  any  mechanical  measures  for  admitting  air  into  the  lungs, 
as  these,  he  says,  are  almost  invariably  followed  by  death  from  pneumonia. 
With  OTU"  improved  methods  of  after-treatment  the  operation  of  trache- 
otomy is,  however,  less  often  followed  by  fatal  consequences  than  was  for- 
merly the  case  ;  and  if  the  dyspnoea  is  \irgent  and  threatens  life,  I  should 
not  hesitate  to  advocate  the  procedure,  putting  the  child  afterwards  in  a 
tent-bedstead  in  a  warmed  and  moistened  atmosphere. 

The  calomel  treatment  certainly  seems  to  offer  good  results.  In  each 
of  Dr.  Bevan's  cases  the  patient  took  between  fifty  and  sixty  grains  of 


STEIDULOUS   LARTJS'GITIS — 3I0EBID   ANATOMY.  411 

calomel ;  and  of  four  children  treated  in  this  manner,  although  the  symp- 
toms were  excessively  severe,  all  recovered  without  any  sign  of  having  been 
injuriously  affected  by  the  remedy.  In  addition  to  giving  calomel  by  the 
mouth,  mercurial  inunctions  were  used  in  the  worst  cases  to  the  skin  ;  a 
few  leeches  were  applied  to  the  upper  part  of  the  chest ;  and  the  bowels 
were  relieved  by  a  copious  enema.  In  each  case,  too,  the  treatment  was  be- 
gun by  an  emetic  to  clear  out  the  stomach.  Dr.  Bevan  states  that  green 
stools  may  be  expected  in  fi'om  eight  to  twenty-six  hours  after  the  first 
dose  of  the  calomel. 

It  is  important  to  support  the  strength.  If  there  is  total  inability  to 
swallow,  the  patient  must  be  fed  with  white- wine  whey  by  the  stomach- 
tube  passed  through  the  nose. 

In  cases  of  chronic  laryngitis  the  throat  should  be  brushed  every  two 
or  three  days  with  a  strong  solution  of  perchloride  of  iron.  A  little  boy, 
aged  one  year  and  eleven  months,  was  under  my  care  for  chronic  hoarse- 
ness of  three  months'  standing.  The  child,  although  anaemic,  had  a  healthy 
appearance,  and  there  was  no  history  of  syphilis  or  trace  of  the  disease 
about  the  body.  He  was  quickly  cured  by  the  application  to  the  larynx 
every  third  morning  of  a  solution  of  perchloride  of  iron  in  glycerine  (two 
drachms  of  the  strong  solution  to  the  ounce).  The  application  caused  no 
spasm  or  other  uncomfortable  symptom. 

iron  and  cod-liver  oil  are  useful  in  these  cases  ;  and  the  throat  may  be 
painted  externally  with  tincture  of  iodine, 

STRIDULOUS  LARYNGITIS. 

Stridulous  laryngitis  (false  croup,  catarrhal  croup,  spasmodic  laryngitis) 
is  a  common  affection  in  early  life.  For  a  long  time  it  was  confounded 
with  diphtheritic  laryngitis,  and  no  doubt  a  sharp  attack  of  laryngeal  ca- 
tarrh with  spasm  produces  sufficiently  serious  symj^toms.  The  disease, 
however,  is  rarely  fatal. 

Causation. — Stridulous  laryngitis  is  especially  a  disease  of  childhood 
after  the  period  of  infancy  has  passed,  for  it  is  comparatively  rare  under 
the  age  of  two  years.  Between  the  second  and  seventh  year  the  disorder 
is  common  ;  but  after  the  latter  date  it  again  becomes  exceptional.  I  have 
met  with  it,  however,  as  late  as  the  fourteenth  year.  When  it  occurs  in 
the  course  of  the  second  year  the  patient  will  be  usually  found  on  exam- 
ination to  be  the  subject  of  rickets.  The  complaint  appears  to  be  predis- 
posed to  by  an  hereditary  spasmodic  tendency  ;  but  the  patients  are  not 
necessarily  in  any  way  feeble  or  under-nourished.  As  a  rule,  perhaps  they 
are  sturdy  looking  and  strong.  Boys  are  attacked  twice  as  often  as  girls  ; 
and  the  affection  is  frequently  seen  more  than  once  in  the  same  individual ; 
indeed,  it  may  be  said  to  have  a  tendency  to  recur. 

The  exciting  causes  of  the  complaint  are  those  common  to  laryngeal 
catarrh.  The  affection  is  sometimes  an  early  symptom  of  measles  and 
whooping-cough.  It  may  occur  as  a  complication  in  the  course  of  the 
latter,  and  occasionally  returns  under  the  influence  of  a  slight  chill  after 
the  attack  of  pertussis  is  at  an  end. 

Morbid  Anatomy. — In  the  rare  cases  where  death  has  resulted  from 
this  complaint  the  glottis  and  vocal  cords  have  been  found  little  altered, 
or  more  or  less  uniformly  reddened.  Sometimes  they  have  been  slightly 
swollen.  An  excess  of  mucus  has  been  usually  present.  It  is  stated  that 
small  linear  ulcers  have  been  sometimes  noticed  on  close  inspection  of  the 
vocal  cords. 


412  DISEASE   IN   CHILD EETir, 

6'?/"i/3fom.s.  —  Stridulous  laryngitis  consists  of  a  catarrh  of  the  larynx 
with  superadded  spasm — the  spasmodic  element  being  probably  the  con- 
sequence of  special  nervous  excitabihty  in  the  individual  patient.  In  some 
children  (and  these  are  usually  rickety  infants)  a  veij  trifling  degree  of 
catarrh  may  induce  spasm.  These  cases  are  very  mild  as  a  rule,  and  quickly 
subside.  In  older  children  the  catarrh  is  more  serious.  The  complaint 
then  lasts  longer  and  is  accompanied  by  more  violent  symptoms. 

In  the  mildest  form  of  the  complaint  the  pulmonary  catarrh  is  often 
very  trifhng.  The  child  may  be  put  to  bed  apparently  well,  or  with  merely 
a  slight  cold.  About  eleven  or  twelve  o'clock  he  starts  up  suddenly  from 
his  sleep  with  a  hoarse,  barking,  sonorous  cough,  and  a  loud,  whistling,  stri- 
dor in  his  breathing.  It  will  be  noticed,  however,  that  the  stridulous 
character  is  confined  to  the  inspiration,  and  that  the  expu-ation  is  short  and 
comparatively  noiseless.  The  movements  of  the  chest  are  laboured  and 
violent,  the  soft  parts  sink  in  at  each  inspiration,  the  nares  act,  and  the 
eyes  are  staring  and  frightened-looking.  If  the  impediment  to  breathing- 
is  great,  the  face  becomes  Uvid,  the  eyes  are  injected,  and  the  child  is  ex- 
cessively restless  and  agitated.  His  voice,  however,  remains  hoarse  and 
loud.  It  is  rarely  weak,  and  only  becomes,  suppressed  and  whispering  in 
cases  of  exceptional  severity. 

The  seizure  lasts  from  a  few  minutes  to  half  an  hour,  or  even  longer, 
for  sometimes,  after  aj)pearing  to  relax,  the  spasm  becomes  again  distress- 
ing. In  the  end  it  subsides  completely  and  the  child  falls  asleep,  but  he 
may  again  be  roused  up  by  a  milder  seizure  a  few  hours  afterwards.  On 
the  following  morning  he  may  wake  up  apparently  well,  or  with  some 
shght  thickness  of  the  voice  and  a  loud  clang  in  his  cough,  but  these  symp- 
toms pass  off  after  a  day  or  two.  In  many  cases  the  attack  retui-ns  on  the 
following  night,  and  may  be  repeated  yet  a  thh'd  time,  but  the  symptoms 
are  seldom  so  severe  as  on  the  first  occasion.  During  the  attack  the  tem- 
perature may  rise  to  102°  or  103°,  or  higher,  but  in  the  morning  is  usually 
normal. 

In  more  severe  cases  of  stridulous  laryngitis  the  comj)laint  does  not 
pass  off  so  quickly.  The  catarrh  is  often  not  limited  to  the  larynx,  but 
also  occupies  the  bronchi.  The  attacks  then  occur  not  only  at  night  but 
also  in  the  daytime,  and  in  the  intervals  the  breathing  is  more  or  less  op- 
pressed and  "  croupy,"  and  the  voice  and  cough  hoarse.  The  dyspnoea  in 
these  cases  may  be  a  very  serious  s;)TQptom,  the  child  having  the  greatest 
difficulty  in  obtaining  even  a  minimum  supply  of  air.  Indeed,  in  the  worst 
cases  during  the  access  the  face  is  li^dd,  the  hands  and  nails  grow  pxu-ple, 
the  eyes  become  fixed,  convulsive  twitchings  are  noticed  in  the  limbs,  and 
an  examination  of  the  chest  may  detect  signs  of  collapse  at  the  bases  of  the 
lungs.  In  rare  instances  the  patient  dies  suffocated  unless  relieved.  The 
complaint  is  accompanied  by  moderate  fever  which  persists  between  the 
attacks,  and  the  complexion  remains  pale,  with  some  lividity  about  the  lips, 
until  the  free  passage  of  air  is  again  completely  restored.  An  examination 
of  the  urine  seldom  detects  albumen,  but  in  the  worst  attacks,  probably 
from  renal  congestion,  albuminuria  may  be  present. 

A  healthy-looking  boy,  aged  four  years  and  two  months,  was  taken  ill 
on  March  1st  with  sneezing,  coughing,  and  signs  of  tightness  of  the  chest. 
The  same  night  he  was  roused  by  a  severe  attack  of  dyspnoea,  his  breath- 
ing was  oppressed  and  stridulous,  and  his  cough  loud  and  clanging.  AU 
the  next  day  his  voice  was  weak  and  hoarse,  and  his  cough  barking  and 
hard. 

When  the  child  was   seen  on  March  4th,  his  cough  was  hoarse  and 


STRIDULOUS   LARYNGITIS — SYMPTOMS — DIAGNOSIS.  413 

loud.  The  breathing  was  laboured,  46  ;  the  pulse,  140  ;  the  temperature, 
101.4°.  The  skin  was  moist.  The  respiratory  movements  were  very  labo- 
rious, the  shoulders  rising  and  falling,  and  the  soft  parts  of  the  chest  and 
the  epigastrium  sinking  in  deeply.  The  chest  was  resonant,  and  the  breath- 
sounds  were  loud  and  snoring.  One-sixth  of  a  grain  of  tartrate  of  anti- 
mony was  given  every  three  hours'in  a  saline  mixture. 

On  the  night  of  the  5th  the  child  had  another  severe  attack  of  dysp- 
noea. He  was  accordingly  j)u.t  into  a  tent-bedstead  and  the  air  was  kept 
moistened  by  the  steam-kettle.  The  next  day  the  cough  was  loose,  and  the 
voice,  although  hoarse,  was  much  stronger.  The  dyspnoea  did  not  return, 
and  the  child  was  discharged  convalescent  on  March  11th.  The  tempera- 
ture remained  over  100'^,  morning  and  evening,  until  March  9th. 

In  an  ordinary  case  of  moderate  severity  the  cough  loses  its  hard,  bark- 
ing character  after  a  few  days  and  becomes  loose,  the  hoarseness  of  voice 
diminishes,  and  the  child  is  soon  convalescent.  If,  however,  there  be 
general  pulmonary  catarrh,  any  neglect  may  easily  aggravate  the  case  into 
one  of  broncho-pneumonia,  or  in  a  weakly  subject  collapse  of  the  lung  may 
occur.  In  either  case  the  child  may  die.  Fatal  cases  of  laryngitis  stridulosa 
are  in  the  large  majority  of  cases  so  complicated,  for  few  children  die  from 
the  dyspnoea  alone. 

In  rare  cases  stridulous  laryngitis,  like  laryngismus  stridulus,  may  be  ac- 
companied by  carpo-pedal  contractions.  A  little  girl,  between  four  and  five 
years  old,  was  brought  to  me  for  contraction  of  the  fingers,  which  had  much 
alarmed  her  jDarents  and  made  them  fear  that  the  child  was  "going  to  be 
paralysed."  The  patient  was  much  emaciated  from  long-continued  intes- 
tinal catarrh,  and  had  a  pained  expression  of  face.  For  a  month  she  had 
had  a  cough,  and  at  night  was  often  roused  by  attacks  of  stridulous  laryn- 
gitis, in  which  respiration  became  noisy,  and  she  seemed  to  have  much  dif- 
ficulty in  getting  her  breath.  On  examining  her  hands  the  fingers  were 
found  to  be  unusually  straight-looking,  the  hands  being  bent  only  at  the 
knuckles.  The  child  could,  however,  squeeze  well  with  both  hands.  It 
was  stated  that  the  fingers  would  often  become  quite  stiff,  with  the  thumbs 
turned  rigidly  into  the  palms  of  the  hands.  The  girl  was  not  rickety ; 
her  lungs  were  healthy  ;  and  there  was  no  enlargement  of  the  abdominal 
organs  or  mesenteric  glands.  An  iron  mixture  was  prescribed,  and  the 
child  was  ordered  some  claret  with  her  dinner.  Under  this  treatment  the 
symptoms  soon  subsided  and  the  patient  regained  flesh  and  strength. 

Diagnosis. — Stridulous  laryngitis  must  not  be  confounded  with  true 
membranous  crouj) — a  disease  to  which  it  often  presents  a  striking  resem- 
blance. A  distinction  between  these  two  affections  is  of  the  utmost  prac- 
tical importance  ;  for  the  operation  of  tracheotomy,  which  is  especially  in- 
dicated in  cases  of  membranous  laryngitis,  is  rarely  if  ever  necessary  in  the 
stridulous  disorder,  and  if  performed  imports  into  the  case  an  element  of 
danger  which  would  otherwise  be  wanting. 

In  laryngitis  stridulosa  the  invasion  is  much  more  sudden,  and  the 
dyspnoea  at  once  attains  its  maximum  intensity  ;  indeed,  if  the  attack  be 
repeated  it  seldom  reaches  the  violence  of  its  first  access.  The  voice  in 
false  croup,  although  weakened  and  hoarse,  is  rarely  suppressed,  and  the 
child,  if  persuaded  to  exert  himself,  can  usually  speak  fairly  loudly.  Even 
young  children,  although  silent  and  unAvilling  to  cry  when  much  hampered 
for  breath,  if  disposed  to  do  so,  can  often  emit  a  considerable  volume  of 
sound.  The  cough,  too,  is  loud  and  clanging,  and  rarely  assumes  the 
muffled,  whispering  character  so  distinctive  of  membranous  laryngitis. 
Again,  the  stridor  of  the  breathing  is  chiefly  marked  in  inspiration,  the 


414  DISEASE   IN   CHILDEEN". 

expiration  being  much  easier  and  comparatively  noiseless.  In  false  croup, 
also,  there  is  no  enlargement  of  the  submaxillary  glands,  such  as  is  apt  to 
occur  in  cases  of  membranous  laryngitis  when  there  is  any  accompanying 
affection  of  the  pharynx.  An  examination  of  the  urine  rarely  discovers  the 
presence  of  albumen. 

In  aU  these  features  the  stridulous  catarrh  differs  from  the  membranoue 
inflammation.  In  the  latter  the  dyspnoea  begins  gradually  and  attains  its 
maximum  by  degrees  ;  the  voice  becomes  entirely  suppressed  ;  the  cough 
is  a  hoarse  muffled  sound  which  is  almost  pathognomonic  ;  the  stridor  is 
as  marked  in  expiration  as  it  is  in  inspiration  ;  and  albuminuria  is  some- 
times met  with.  Lastly,  in  true  membranous  croup  the  diphtheritic 
exudation  can  often  be  discovered  in  the  pharynx.  Still,  absence  of  exu- 
dation is  not  to  be  depended  upon  as  excluding  diphtheria,  for  the  mem- 
brane may  be  limited  to  the  air-passages,  and  fragments  are  not  always 
coughed  up.  In  a  doubtful  case,  where  the  symptoms  of  spasmodic  laryn- 
gitis are  exceptionally  severe,  the  points  to  be  relied  upon  for  excluding 
diphtheritic  croup  are  :  The  severe  and  sudden  onset  ;  the  comparative 
absence  of  stridor  in  the  expiration  ;  and  the  quality  of  the  voice,  which  is 
not  completely  muffled  or  suppressed.  The  age  of  the  patient  is  also  of 
some  practical  value  in  diagnosis.  In  a  child  under  twelve  months  old,  or 
over  seven  years,  the  case  is  very  unlikely  to  be  one  of  stridulous  laryngitis. 

Laryngitis  stridulosa  may  be  also  confounded  with  laryngismus  stridu- 
lus, with  retro-pharyngeal  abscess,  and  with  oedema  of  the  glottis.  The 
distinctive  characters  of  the  first-named  complaint  are  elsewhere  described 
(see  page  271).  Retro-pharyngeal  abscess  is  at  once  recognised  by  the  in- 
ability of  the  child  to  breathe  when  lying  down,  the  increase  to  his  distress 
occasioned  by  pressui-e  on  the  larynx,  and  the  presence  of  a  sweUing  at  the 
back  of  the  throat.  (Edema  of  the  glottis  is  usually  the  consequence  of  a 
scald  or  burn,  or  follows  an  attack  of  acute  specific  disease  ;  the  distress  is 
more  continuous,  without  marked  remissions  in  the  dyspnoea,  and  the 
thickened  epiglottis  can  be  felt  with  the  finger. 

Prognosis. — As  a  rule,  the  child  has  a  good  prospect  of  recovery,  even  in 
serious  cases,  if  the  operation  of  tracheotomy  be  not  performed.  The  most 
urgent  dyspnoea  usually  subsides  under  suitable  treatment,  and  it  is  very 
rare  for  the  child  to  die  suffocated.  When  the  disease  ends  fatally,  the  un- 
favourable issue  is  usually  the  consequence  of  an  inflammatory  compHca- 
tion.  Stridulous  laryngitis  sometimes  accompanies  the  onset  of  a  pneu- 
monia, or  from  w^ant  of  proper  precautions  the  tracheal  catarrh  may  be 
allowed  to  extend  into  the  finer  tubes.  In  such  a  case  the  prognosis  is  not 
favourable,  for  attacks  of  sufibcation  occurring  in  a  child  the  subject  of 
bi-onchitis  or  pneumonia  are  necessarily  dangerous.  Still,  even  in  these 
cases  the  child  may  recover,  for  often  the  spasm  becomes  less  marked 
when  the  inflammatory  complication  declares  itself. 

Treatment. — In  the  milder  attacks  of  laryngitis  stridulosa  the  child  should 
be  at  once  placed  in  a  warm  bath  (95°  Fah.)  for  fifteen  or  twenty  minutes, 
and  should  be  made  to  vomit  by  a  dose  of  ipecacuanha  wine.  Afterwards 
a  small  dose  of  chloral  (gr.  iij.-iv.  to  child  of  eighteen  months  old)  may  be 
given,  with  a  few  drops  of  sal  volatile,  to  prevent  a  relapse  in  the  course  of 
the  night.  In  the  morning  it  is  well  to  prescribe  a  diaphoretic  mixture 
(such  as  vini  ipecacuanhse,  iTlx.  ;  liq.  ammoniee  acetatis,  lUxx.  ;  glycerini, 
TTix.  ;  aq.  ad  3  j.),  to  be  taken  every  three  or  four  hours,  and  to  give  dii-ectiona 
that  the  child  be  kept  in  one  room  of  a  suitable  temperature.  If  the 
tongue  is  loaded,  a  grain  of  calomel  should  be  given  with  two  grains  of 
jalapine. 


TUBERCULAE   LAEYNGITIS — CAUSATIOJST.  415 

In  tlie  very  severe  cases  a  warm  bath  is  also  useful.  Afterwards  the 
child  should  be  placed  in  a  tent-bedstead,  in  a  warmed  and  moistened 
atmosphere,  as  recommended  for  membranous  croup.  An  emetic  in  all 
these  cases  produces  great  relief.  A  teaspoonful  of  ipecacuanha  wine,  or  a 
quarter  of  a  grain  of  sulphate  of  copper,  may  be  given  every  ten  minutes 
until  the  desired  effect  is  produced.  The  vomited  matters  in  all  severe 
cases  should  be  searched  for  shreds  or  patches  of  false  membrane.  As 
long  as  there  is  fever  the  child  must  be  kept  in  bed,  and  while  the  voice 
remains  hoarse  it  is  wise  to  keep  the  air  moistened  by  means  of  the  steam- 
kettle  (see  page  103).  Tracheotomy  is  rarely  if  ever  necessary  in  mere 
spasmodic  laryngitis.  The  most  violent  attack  of  suffocation  seldom  fails 
to  be  relieved  by  a  warm  bath,  an  emetic,  and  steam  inhalations.  Graves' 
plan  of  applying  a  sponge  wrung  out  of  hot  water  to  the  neck,  below  the 
chin,  is  also  of  service.  It  must  not  be  forgotten  to  attend  to  the  bowels, 
and  a  mercurial  purge  is  a  great  help  to  the  other  treatment. 

If  the  spasms  return  repeatedly,  which,  however,  is  rai-ely  the  case  if 
the  above  treatment  have  been  adopted,  an  antispasmodic  may  be  re- 
quired. Chloral  is  perhaps  the  best,  and  may  be  given  to  a  child  of  two 
years  of  age  in  doses  of  three  grains  three  times  a  day. 

If  any  inflammatory  complication  arise,  such  as  bronchitis,  pneumonia, 
etc.,  special  measures  must  be  adopted  as  recommended  for  these  diseases. 
If  the  case  be  uncomplicated,  diaphoretics  should  be  given  when  the  spasm 
subsides,  and  the  child  should  be  treated  for  an  ordinary  pulmonary  catarrh, 
taking  care  to  withhold  all  stimulating  expectorants  as  long  as  the  cough 
continues  barking  and  hard.  Sometimes  a  few  drops  of  paregoric  added  to 
the  saline  expectorant  mixture  seem  to  aid  its  effect  in  reducing  the  hard- 
ness of  the  cough.  All  the  time  the  diet  must  be  regulated  as  dii^ected 
for  pulmonary  catarrh. 

In  cases  where  the  attacks  of  laryngitis  tend  repeatedly  to  recur, 
endeavours  must  be  made  to  strengthen  the  child  and  diminish  his  sus- 
ceptibility to  changes  of  temperature.  He  should  be  dressed  from  head  to 
foot  in  woollen  underclothing  ;  should  pass  much  of  his  time  out  of  doors  ; 
and  should  have  a  cold  douche  every  morning,  given  with  all  the  precau- 
tions recommended  in  a  jDrevious  chapter  (see  page  17).  Moreover,  as 
children  with  this  tendency  often  have  cold  feet,  care  should  be  taken  that 
the  extremities  are  thoroughly  warm  when  the  child  leaves  the  house.  A 
little  alcohol  with  the  dinner  is  a  useful  medicine  in  these  cases. 

TUBERCULAR  LARYNGITIS. 

In  childhood  the  laryngeal  mucous  membrane  is  comparatively  rarely 
the  seat  of  the  gray  granulation  ;  for  it  is  only  in  after-life  that  laryngeal 
phthisis  becomes  a  common  manifestation  of  the  tubercular  cachexia. 
Still,  even  at  this  early  age  tubercular  granules  and  ulcerations  are  occa- 
sionally present ;  and  these  usually  occur  in  cases  where  the  force  of  the 
disease  is  expended  more  particularly  upon  the  lungs,  the  other  organs 
being  comparatively  unaffected. 

Causation. — Ulcers  of  the  larynx  are  much  more  common  than  tuber- 
cular granules  without  breach  of  surface.  MM.  EilHet  and  Barthez  state 
that  they  have  only  met  with  a  single  case  of  tubercle  of  the  laryngeal 
mucous  membrane  unaccompanied  by  ulceration,  and  quote  a  second  from 
M.  Tonnele,  which  occurred  in  a  child  of  fourteen.  According  to  these 
authors,  the  ulcers  are  usually  of  small  size,  varying  from  the  head  of  a  pin 
to  a  large  lentil.     They  are  circular  and  cleanly  cut,  unless  they  occupy 


416  DISEASE   11^   CHILDEEJS". 

the  vocal  cords.  In  that  case  they  are  more  commonly  oval,  with  their 
long  diameter  in  the  dii'ection  of  the  cord.  Their  borders  are  thin  and 
reddish  in  colour,  and  their  base  is  usually  composed  of  the  submucous 
tissue — rarely  of  the  muscular  fibres.  The  ulcers,  for  the  most  part,  are 
single,  although  sometimes  more  than  one  is  present  in  the  same  case. 
The  seat  may  be  one  or  other  of  the  vocal  cords,  or  the  posterior  angle  of 
the  glottis,  or  the  base  of  the  epiglottis.  The  mucous  membrane  is  unal- 
tered or  thickened  ;  sometimes  it  is  reddened. 

The  trachea  and  lai'ger  bronchi  may  be  also  the  seat  of  ulcers,  but  more 
usually  the  tracheal  mucous  membrance  is  merely  reddened  and  thickened. 

Symptoms. — The  symptoms  of  the  larj-ngeal  complication  are  often  in- 
definite. There  may  be  merely  some  alteration  of  the  voice,  shght  pain  in 
the  region  of  the  larynx,  and  if  there  is  much  swelling,  dyspnoea.  The 
voice  is  often  thick  and  husky  ;  it  is  never  whispering  as  in  the  adult. 
The  cough  is  little  altered,  and  has  no  special  quality  pointing  to  this  par- 
ticular lesion.  There  is  seldom  pain  or  diificulty  of  deglutition  ;  and  the 
pain  in  the  larynx,  if  present  at  all,  is  rarely  of  much  moment.  The  small 
size  and  limited  number  of  the  sores  is  sufficient,  no  doubt,  to  account  for 
the  absence  of  special  symptoms  ;  for  in  the  adult,  when  aphonia  is  present, 
the  ulceration  is  generally  extensive. 

Dyspnoea  may  be  a  marked  symptom.  A  little  boy,  aged  two  years 
and  nine  months,  whose  father  had  died  of  consumption,  was  admitted 
into  the  hospital,  under  my  care,  for  difficulty  of  breathing.  For  six  weeks 
pre-v'iously  his  breath  had  been  noticed  to  be  short,  and  for  a  fortnight  his 
respiration  had  been  accompanied  by  a  stridor.  For  three  weeks  he  had 
been  unable  to  swallow  any  sohd  food,  although  he  could  take  hquids  with- 
out difficulty. 

On  admission  his  dyspnoea  was  marked.  At  each  inspiration  the  lower 
half  of  the  breastbone  was  bent  deeply  inwards,  so  as  to  leave  a  pit  in  the 
epigastrium.  At  the  same  time  the  intercostal  spaces  and  supra-clavicular 
hollows  were  markedly  retracted.  His  nares  worked,  and  ah  the  accessory 
muscles  of  respiration  were  in  strong  action.  There  was  some  lividity  of 
the  face,  and  the  breath-sound  was  accompanied  by  a  hoarse  stridor.  His 
voice  was  hoarse,  but  not  whispering.  The  cough  was  little  altered,  and 
had  no  metallic  or  ringing  quality.  On  examination  of  the  chest  there  was 
some  dulness  at  each  supra-spinous  fossa,  and  much  coarse  bubbling  was 
heard  all  over  both  limgs.  Temperatui'e  at  6  p.m.,  101.6^;  respii'ations,  40; 
pulse,  136.     There  was  no  albumen  in  the  uiine. 

The  boy  was  in  the  hospital  a  week.  His  dyspnoea  aU  the  time  con- 
tinued with  little  change.  There  were  no  exacerbations  or  remissions. 
His  temperature  varied  between  100.6°  in  the  morning,  and  102°  to  103°  at 
night.  His  bowels  acted  twice  a  day,  as  a  rule,  although  in  one  day  he 
was  purged  seven  times ;  and  he  never  complained  of  pain  in  the  abdomen 
until  a  few  hours  before  the  end.  His  death  occuiTed  quite  suddenly. 
The  child,  after  comj)laining  of  stomach-ache,  which  did  not  appear  to  be 
severe,  suddenly  sank  into  a  state  of  collapse,  in  which  he  died. 

On  examination  of  the  body  many  ulcers  were  found  in  the  ilium,  one 
of  which  had  ruptured  and  caused  profuse  extravasation  into  the  peritoneal 
cavity.  The  ulcers  were  circular,  and  did  not  foUow  the  course  of  the 
vessels,  as  in  ordinary  tubercular  or  scrofulous  ulceration.  The  hver  was 
fatty,  but  the  abdominal  organs  seemed  to  be  healthy.  No  gTay  gTanula- 
tions  were  seen  anywhere  but  in  the  lungs.  These  organs,  however,  were 
stuffed  with  them  ;  and  there  was  some  consolidation  at  the  apices.  The 
mucous- membrane  of  the  larynx  and  epiglottis  was  excessively  swollen  and 


TUBERCULAR   LARYNGITIS — DIAGNOSIS.  417 

red,  so  tliat  the  glottis  formed  a  mere  chink.  No  ulcerations  were  discov- 
ered in  this  part,  and  my  notes  make  no  mention  of  gray  granulations  about 
the  larynx.  The  trachea  was  healthy,  and  nowhere  was  there  any  sign  of 
false  membrane. 

In  this  interesting  case  the  larynx  was  the  seat  of  severe  chronic  inflam- 
mation, and  had  the  child  lived  a  short  time  longer  it  is  probable  that 
ulcers  would  have  formed  in  the  glottis.  As  it  was,  the  intestinal  comjDli- 
cation  carried  him  off  before  any  further  change  could  take  place. 

Diagnosis. — In  the  child,  on  account  of  the  extreme  difficulty  of  using- 
the  laryngoscope,  owing  to  the  resistance  of  the  patient,  it  is  very  rare  to 
be  able  to  ascertain  by  actual  inspection  the  existence  of  ulcers  or  granules 
on  the  lar^^ngeal  mucous  membrane.  In  children  who  have  reached  the  age 
of  ten  or  twelve  years  the  instrument  may,  however,  be  sometimes  used ; 
but  great  irritability  of  the  fauces  usually  attends  any  laryngeal  catarrh, 
and  the  attempt  to  inspect  the  throat  has  often  to  be  abandoned. 

In  coming  to  the  conclusion  that  a  child  has  tubercular  ulceration  of 
the  glottis  we  must  first  exclude  ulceration  from  other  causes.  Syphilis ' 
must  be  set  aside  by  inquiry  into  the  family  history,  and  special  antece- 
dents of  the  patient,  and  by  careful  examination  of  the  body  for  signs  of  the 
inherited  disease.  We  must  also  make  sure  that  the  child  has  not  suffered 
lately  from  any  complaint  which  tends  to  give  rise  to  chronic  inflammation 
or  ulceration  of  the  larynx,  such  as  measles,  small-pox,  or  membranous 
croup.  If  all  these  diseases  can  be  excluded,  and  we  find  hoarseness  of  the 
voice  and  cough,  with  stridulous  breathing,  in  a  child  who  is  evidently  suf- 
fering from  tuberculosis,  we  cannot  but  explain  the  local  symptoms  in  the 
light  of  the  general  disease.  A  persistent,  steady  dysj)noea,  without  exacerba- 
tions or  remissions,  would  add  strength  to  the  explanation.  If,  however, 
suffocative  attacks  come  on,  and  the  child  is  first  seen  when  suffering  from 
more  or  less  jDaroxysmal  dyspnoea,  an  exact  diagnosis  may  be  very  difficult. 
The  history  would,  indeed,  point  to  a  chronic  interference  with  the  action 
of  the  glottis  ;  but  such  interference  might  be  produced  by  warty  growths 
or  polypi  of  the  vocal  cords,  and  without  a  laryngoscopic  examination  a 
diagnosis  is  probably  impossible.  Such  a  case  as  the  following,  for  example, 
would  give  rise  to  great  perplexity. 

A  little  boy,  four  years  old,  but  short  for  his  age,  and  of  rickety  build, 
who  had  been  treated  for  syphilis  in  his  infancy,  is  brought  to  the  hospital 
for  difficulty  of  breathing.  It  is  said  that  for  four  months  he  has  been 
noticed  to  breathe  stertorously  and  to  have  a  hoarse  cough.  The  cough  is 
worse  at  night,  and  is  often  followed  by  vomiting.  The  child's  face  is. 
rather  turgid  and  congested,  and  the  jugular  veins  are  visible.  On  inspec- 
tion of  the  chest  it  is  seen  that  at  each  inspiration  the  ribs  and  lower  half 
of  the  breast-bone  are  greatly  retracted.  At  the  same  time  the  pulse  fails 
in  force,  and  there  is  a  stridulous  sound  from  the  throat.  Examination  of 
the  chest  shows  no  sign  of  disease ;  resonance  is  normal,  and  a  loud  stridor 
conducted  from  the  throat  is  heard  at  all  parts  of  the  chest-wall.  The 
heart's  apex  is  in  the  normal  site.  An  attempt  to  make  a  laryngoscopic 
examination  has  to  be  abandoned  on  account  of  the  child's  struggles. 
Temperature  at  9  a.m.,  101.8°  ;  pulse,  140  ;  respirations,  36. 

After  admission  into  the  hospital  the  temperature  for  the  first  eleven 
days  is  over  100°,  both  morning  and  evening.  The  child  is  found  to  suffer 
from  severe  fits  of  dyspnoea,  which  come  on  usually  at  night.  In  these 
attacks  he  is  excessively  agitated,  sitting  up  in  bed  and  throwing  himself 
about,  his  face  gets  livid  and  his  lips  are  blue.  He  makes  constant  at- 
tempts to  cough,  as  if  to  remove  some  obstacle,  but  the  cough  is  very  hoarse 
27 


418  DISEASE  IIST   CHILDEEE". 

and  smothered.  In  one  of  these  attacks  the  distress  is  so  great,  and  the 
signs  of  approaching  suffocation  so  pronounced,  that  tracheotomy  is  per- 
formed. After  the  operation  the  breathing  is  easier,  but  signs  of  pneu- 
monia manifest  themselves,  and  the  child  dies.  After  death  an  examination 
of  the  larynx  discovers  several  warty  growths  attached  to  the  true  vocal 
cords.     One  of  these  growths  is  long  and  pedunculated. 

In  a  case  such  as  the  above,  if  a  correct  diagnosis  can  be  arrived  at  in 
the  absence  of  a  laryngoscopic  examination,  it  can  only  be  by  exclusion; 
but  the  elevated  temperature  would  be  an  element  of  perplexity,  and 
would  not  be  in  favour  of  warty  growths.  A  digital  examination  is  of  little 
value  in  such  a  case,  for  the  growths,  being  seated  on  the  true  vocal  cords, 
are  quite  out  of  reach  of  the  finger. 

Prognosis. — The  prognosis  is  always  unfavourable,  but  the  gravity  of 
the  case  depends  much  upon  the  general  disease  and  httle  upon  the  laryn- 
geal comj)lication.  It  is  only  in  cases  where  the  inflammatory  swelling 
has  almost  occluded  the  ojDening  of  the  glottis  that  any  special  danger  is 
likely  to  arise  from  the  condition  of  the  larynx.  These  cases,  fortunately, 
appear  to  be  very  rare. 

Treatment. — Little  can  be  done  in  the  way  of  special  medication  for  tu- 
bercular laryngitis.  The  treatment  to  be  adopted  must  consist  of  the 
measures  recommended  in  cases  of  simple  inflammation.  The  neck  should 
be  kept  warm  externally,  and  inhalations  of  steam,  medicated  with  the 
compound  tincture  of  benzoin,  should  be  prescribed.  If  the  cough  is 
troublesome  and  disturbs  the  rest,  small  doses  of  laudanum,  morphia,  or 
paregoric  may  be  administered.  Two  to  three  drops  of  liquor  morphiae, 
with  the  same  quantity  of  spirits  of  chloroform  and  ten  of  glycerine,  in  a 
teaspoonful  of  water,  form  a  useful  linctus  for  these  cases.  The  general 
•treatment  must  be  that  recommended  for  the  constitutional  affection. 


CHAPTER  III. 

SUPPURATION  ABOUT  THE  LAEYNX. 

The  formation  of  an  abscess  in  connection  with  the  larynx  is  not  a  com- 
mon complaint  at  any  period  of  life.  But  the  disease,  when  present  in  the 
child,  causes  so  much  interference  with  respiration,  and  produces  symptoms 
which  bear  so  close  a  resemblance  to  those  of  membranous  croup,  that  it 
must  not  be  passed  over  without  a  word  of  notice. 

Three  cases  of  suppuration  about  the  larynx  were  published  some  years 
ago  by  Dr.  W.  Stephenson,  of  Aberdeen.  Two  others  have  been  placed 
upon  record  by  Dr.  John  S.  Parry,  of  Philadelphia.  A  few  cases  are  also 
scattered  about  in  the  various  journals. 

Causation. — A  state  of  feeble  health  appears  to  favour  the  occurrence 
of  the  disease,  for  the  patient  is  generally  weakly  and  cachectic-looking. 
In  two  of  Dr.  Stephenson's  cases  the  child  was  just  convalescent  from  an 
acute  specific  disease  (scarlatina  and  small-pox).  In  a  case  narrated  by 
MM.  RiUiet  and  Barthez,  under  the  name  of  submucous  laryngitis,  the  boy 
(aged  four  years  and  a  half)  was  still  in  a  weakly  condition  after  an  attack 
of  measles.  A  preliminary  period  of  ill-health  is  not,  however,  indispen- 
sable, for  in  one  of  Dr.  Parry's  cases  (a  little  negro  baby  of  four  and  a  half 
months  old)  the  infant  seemed  to  be  in  perfect  health  just  before  the  first 
symptoms  appeared. 

Morbid  Anatomy. — The  abscess  is  usually  situated  at  some  point  in  the 
immediate  neighbourhood  of  the  larynx.  In  one  of  Dr.  Stephenson's  cases 
its  seat  was  at  the  outer  side  of  the  right  thyroid  cartilage,  laying  baige  the 
upper  margin,  and  extending  to  the  superior  cornu.  It  had  opened  inter- 
nally. In  another  a  sac  containing  pus  was  seated  in  front  of  the  thyroid 
cartilage,  and  extended  upwards  on  each  side  as  far  as  the  upper  margin 
of  the  alse  of  the  cartilage,  the  pouch  on  the  right  side  being  somewhat 
larger  than  that  on  the  left.  In  one  of  Dr.  Parry's  cases  an  exactly  similar 
condition  was  met  with.  The  thyroid  cartilage  itself  may  be  eroded  and 
roughened  and  denuded  of  perichondrium. 

Symptoms. — The  symptoms  produced  by  suppuration  around  the  lar- 
ynx are  very  similar  to  those  which  arise  as  a  consequence  of  retro-pha- 
ryngeal  abscess,  for  in  both  cases  there  is  pressure  upon  the  air  and  food 
passages.  There  is  dyspnoea  and  laboured  breathing  ;  hoarse,  noisy  inspi- 
ration, and  increase  of  distress  in  the  recumbent  position.  Swallowing  is 
greatly  impeded  ;  the  child,  if  an  infant,  refuses  the  breast ;  if  older,  he 
cries  when  an  attempt  is  made  to  force  him  to  take  nourishment.  An 
effort  to  swallow  is  often  followed  by  cough,  and  an  increase  in  the  dysp- 
noea, with  return  of  the  fluid  through  the  mouth  and  nose. 

The  most  prominent  symptom  is  the  dyspnoea.  The  child's  eyes  are 
prominent  and  his  face  dusky.  His  breathing  is  hurried  (40-50)  and  his 
nares  act  with  respiration.  If  an  infant,  he  lies  back,  with  head  retracted 
and  the  muscles  of  the  nucha  rigid.     If  able  to  sit  up,  he  sits  huddled 


420  DISEASE  IN   CHILDEElSr. 

together  in  his  cot  instead  of  lying  down,  and  whimpers  if  disturbed. 
Each  inspiration  is  accompanied  by  a  loud  rattling  stridor,  and  at  the  same 
time  the  soft  parts  of  the  chest  are  retracted  and  the  epigastrium  is 
depressed.  The  expirations  are  short  and  comparatively  noiseless.  The 
difficulty  of  breathing  varies  in  degTee.  It  is  subject  to  exacerbations,  dur- 
ing which  the  child  is  in  the  greatest  agitation,  and  seems  on  the  point  of 
suffocation.  In  the  intervals,  although  quieter,  he  is  still  greatly  distressed. 
Anything  which  irritates  or  distui-bs  the  patient,  such  as  attempts  to  give 
food  or  medicine,  encourages  the  attacks ;  and  if  he  try  to  swallow,  the 
dyspnoea  comes  on  at  once.  The  voice  is  almost  suppressed,  and  the  cry 
is  hoarse  or  whispering.  Cough  is  either  absent  or  is  merely  hoarse  with- 
out clangor.      In  one  case  it  was  paroxysmal. 

The  physical  signs  of  the  chest  are  normal,  with  the  exception  of  the 
loud  stridor  which  is  transmitted  to  all  parts  of  the  chest-wall  and  c[uite 
obscures  the  normal  vesicular  murmur.  On  examination  of  the  throat  the 
fauces  appear  to  be  perfectly  healthy,  and  the  finger  pushed  to  the  back  of 
the  pharynx  finds  no  tumour  such  as  is  present  in  cases  of  retropharyngeal 
abscess.  At  first,  too,  the  most  careful  examination  of  the  neck  may 
detect  no  deviation  from  the  normal  state  ;  but  after  a  few  days  a  little 
swelling  may  perhaps  be  discovered  on  careful  inspection.  In  some  cases 
the  larynx  has  been  usually  prominent  or  pressed  out  of  the  mesial  line. 
The  swelling  in  most  of  the  cases  appeared  at  some  part  of  the  posterior 
border  of  the  thyroid  cartilage,  just  in  front  of  the  sternomastoid  muscle, 
and  in  two  cases  it  spread  to  the  front.  In  one  instance  it  was  noticed  to 
become  more  prominent  in  expiration,  and  to  recede  again  in  inspiration. 
The  swelling  is  not  hard,  and  rarely  fluctuates  ;  indeed,  as  Dr.  Stephenson 
remarks,  "it  may  feel  more  like  air  than  fluid." 

If  the  swelling  is  punctured  and  the  accumulated  pus  let  out,  instant 
relief  is  obtained.  The  dyspnoea  subsides  and  rapidly  disappears ;  the 
child  takes  food  without  hesitation  or  difficulty,  and  the  cough  im- 
proves. The  voice  may,  however,  remain  feeble  for  some  weeks  after- 
wards. The  duration  of  the  disease  is.  short.  In  all  pubhshed  cases 
the  suppuration  ran  an  acute  course,  and  ended  fatally  in  many  instances. 
As  m  the  case  of  abscess  behind  the  pharynx,  death  may  be  the  conse- 
quence of  exhaustion,  or  the  child  ma}'  die  suffocated  in  an  access  of 
dyspnoea. 

Diagnosis. — In  reading  the  above  description  of  the  phenomena  attend- 
ing upon  suppuration  about  the  larynx  the  resemblance  of  the  disease,  in 
its  course  and  symptoms,  to  retro-pharyngeal  abscess  cannot  fail  to  be  re- 
marked. We  find  in  each  instance  difficulty  of  swallowing,  paroxysmal 
dyspnoea  and  stridulous  breathing,  and  a  marked  increase  in  the  child's 
distress  when  he  lies  down.  In  either  case,  too,  the  trachea  may  be  pushed 
out  of  place  and  may  be  more  prominent  than  natural.  The  chief  distin- 
guishing mark  is  the  presence  of  a  tumour  in  the  fauces  if  the  abscess  is 
situated  behind  the  pharynx  ;  while  if  the  suppiu-ation  occurs  around  the 
larynx  the  fauces  are  natural. 

The  distinction  between  such  a  condition  and  membranous  croup  is 
described  elsewhere  (see  page  594).  It  may,  however,  be  here  noticed  that 
in  children  who  are  old  enough  to  sit  upright,  orthopnoea  is  a  very  charac- 
teristic symptom  of  interference  with  the  passage  of  air  through  the  larynx, 
and  trachea  from  outside  pressure.  In  membranous  croup  no  such  symptom 
is  noticed,  for  in  that  disease  there  is  no  aggravation  of  the  dyspnoea  when 
the  child  is  recumbent.  On  the  contrary,  he  often  breathes  more  easily  in 
that  position.     Again,  the  progression  of  the  symptoms  is  more  gradual  in 


SUPPUEATIOISr  ABOUT  XHE   LARYIS'X — TREATJIENT.  421 

tlie  case  of  abscess.  The  stertor  comes  on  more  slowly  and  increases  in 
intensity  as  the  sac  increases  in  size. 

Prognosis. — The  prospect  of  recovery  depends  upon  the  general  health 
of  the  child,  and  upon  the  appearance  of  local  swelling  or  fluctuation  at 
some  point  in  the  front  of  the  neck.  If  the  abscess  can  be  detected  and  its 
contents  evacuated,  recovery  may  take  place  ;  but  if  the  child  be  a  feeble 
cachectic  subject,  especially  if  he  be  much  exhausted  by  sleeplessness  and 
want  of  food,  the  operation  may  come  too  late  to  save  life.  In  this  disease 
the  prognosis  is  distinctly  less  favourable  than  it  is  in  retropharyngeal 
abscess.^ 

Treatment. — If  the  presence  of  an  abscess  about  the  larynx  be  suspected, 
the  throat  should  be  enveloped  in  hot  poultices,  frequently  changed,  so  as 
to  hasten  the  formation  of  matter  and  quicken  its  approach  to  the  surface. 
If  any  swelling  can  be  detected  by  the  side  of  the  thyroid  cartilage,  it 
should  be  punctured  with  a  small  trocar  without  reference  to  the  absence 
of  fluctuation.  Even  if  no  swelling  can  be  seen,  in  cases  where  the  symp- 
toms are  very  urgent  and  we  feel  strong  suspicions  of  the  formation  of  pus 
in  the  neighbourhood  of  the  larynx,  it  is  justifiable  to  make  exploratory 
punctm-es.  Some  point  on  a  line  with  the  posterior  border  of  the  thyi'oid 
cartilage  should  be  chosen  for  the  operation.  "  If  the  exploration  be  at- 
tended by  no  satisfactory  result,  and  the  symptoms  continue  urgent,  trache- 
otomy should  be  performed. 

At  the  same  time  every  effort  should  be  made  to  support  the  strength  of 
the  child.  Port  wine  should  be  given,  or  the  brandy-and-egg  mixture  ; 
and  pounded  meat  made  fluid  with  gravy  or  strong  beef-tea,  eggs  and  milk, 
etc.,  must  be  administered  in  suitable  quantities.  If  the  child  cannot 
swallow,  he  must  be  fed,  if  possible,  through  a  stomach-tube  introduced  by 
the  nose. 


CHAPTER  TV. 

CROUPOUS  PNEUMONIA. 

Croupous  or  lobar  pneumonia  may  be  seen  at  any  period  of  childhood,  but 
in  infancy  is  comparatively  rare.  Up  to  the  end  of  the  second  year  inflam- 
mation of  the  lung  usually  assumes  the  catarrhal  form,  and  even  in  the 
third  year  pneumonia  is  more  often  catarrhal  than  croupous.  After  the 
third  year  both  forms  of  the  disease  are  about  equally  common,  and  with 
each  succeeding  year  inflammation  of  the  lung,  if  it  occurs,  is  more  and 
more  likely  to  be  of  the  croupous  variety. 

Causation. — Of  late  years  a  tendency  has  been  growing  to  look  upon 
croupous  pneumonia  as  an  acute  general  disease,  of  which  the  pulmonary 
consolidation  is  the  anatomical  expression,  and  no  longer  to  regard  it  as  a 
mere  local  inflammation.  Some  observers  have  compared  it  to  acute  rheu- 
matism and  tonsillitis.  Others,  who  see  in  the  affection  the  efiects  of  a  spe- 
cial poison,  have  even  placed  it  in  the  same  class  with  typhoid  fever  and 
other  similar  specific  distempers. 

That  the  disease  is  a  general  one,  with  a  marked  local  manifestation, 
seems  to  be  evident,  for  the  general  symptoms  are  not  proportioned  in 
severity  to  the  extent  of  lung  surface  involved  ;  they  may  precede  by  some 
days  any  evidence  of  local  mischief,  and  the  highest  elevation  of  tempera- 
ture is  often  reached  before  the  point  of  most  complete  consolidation  is 
arrived  at.  Moreover,  the  character  of  the  symptoms  differs  in  many  re- 
spects from  the  ordinary  type  of  constitutional  disturbance  set  up  by  a 
local  injury  :  head  symptoms  are  more  common,  sweating  is  more  frequent, 
and  a  herpetic  eruption  is  an  ordinary  phenomenon.  Again,  the  morbid 
exudation,  which  is  the  chief  local  expression  of  the  disease,  is  of  a  kind 
peculiar  to  pneumonia,  and  cannot  be  produced  by  ordinary  inflammatory 
agency.  Still,  although  the  affection  may  be  a  general  one,  it  does  not 
follow,  as  some  observers  are  disposed  to  believe,  that  it  ought  to  be  classed 
amongst  the  diseases  which  result  from  specific  infection.  There  are  no 
doubt  some  facts  which  seem  to  favour  this  view.  Thus,  pneumonia  has 
been  occasionally  known  to  occur  in  epidemics,  and  in  some  outbreaks 
facts  have  been  noted  which  seem  to  point  to  personal  communication  of 
the  disease  by  contagion.  The  ilhiess  sometimes  appears  to  be  preceded 
by  a  prodromal  interval,  and  to  pass  through  a  stage  of  invasion  before 
local  sj'^mptoms  are  manifested;  it  runs  a  definite,  imiform  course  ;  is  often 
accompanied  by  complications  which  assume  different  degrees  of  prom- 
inence in  different  outbreaks,  and  its  type  varies  in  severity,  the  rate  of 
mortality  being  higher  in  some  epidemics  than  it  is  in  others.  In  all  these 
features  the  disease  seems  to  incline  to  the  class  of  acute  specific  maladies. 
The  question  whether  or  not  the  illness  can  be  set  up  by  impressions  of 
cold,  is  one  of  great  importance,  for  if  it  can  arise  from  a  simple  chill,  the 
disease  can  have  no  pretensions  to  be  the  consequence  of  a  specific  poison. 
There  is  a  conflict  of  testimony  upon  this  point.     It  is  said  that  pneumo- 


CROUPOUS  PNEUMOlSriA— CAUSATIOlSr — MOEBID  ANATOMY.      423 

nia  is  most  frequent  in  the  tropics,  and  diminishes  in  prevalence  as  the 
distance  from  this  zone  increases.  It  is  not  especially  common  in  cold 
latitudes  ;  and  Koch  in  his  cases  failed  to  trace  any  relation  between  the 
attack  and  the  external  temperature.  Other  observers,  however,  have  no- 
ticed a  connection  between  the  illness  and  meteorological  conditions  ;  and 
there  is  no  doubt  that  in  seasons  where  the  temperature  is  changeable  and 
the  weather  damp  the  disease  is  more  common  than  at  times  when  the 
temperature  is  uniformly  high  or  uniformly  low.  Biach  states,  as  a  result 
of  his  observations,  that  the  coincidence  of  rapid  atmospheric  depression,  a 
low  temperature,  and  sudden  changes  of  temperature  tends  to  produce  the 
disease. 

Perhaps  in  the  present  state  of  our  knowledge  it  may  be  sufficient  to 
class  pneumonia  with  tonsillitis,  and,  indeed,  it  bears  a  great  resemblance 
to  that  disease  in  the  conditions  under  which  it  appears  to  originate.  In 
addition  to  cold,  bad  di-ainage  seems  to  have  a  powerful  influence  in  excit- 
ing the  malady.  Many  mysterious  cases  of  pneumonia  arising  in  'schools 
have  been  finally  traced  to  contamination  of  the  air  of  dormitories  by  sewer- 
gas,  and  have  ceased  after  measures  have  been  taken  to  rectify  the  fatdty 
condition  of  the  drains. 

Pneumonia  sometimes  occurs  secondarily  to  other  forms  of  illness. 
Thus  it  may  be  a  consequence  of  an  altered  state  of  the  blood,  as  in  the 
acute  febrile  diseases,  or  may  be  due  to  imperfect  purification  of  the  blood, 
as  in  Bright's  disease.  In  other  cases,  again,  it  may  be  a  purely  accidental 
complication. 

Lastly,  although  pneumonia  often  attacks  children  who  are  to  all  ap- 
pearance strong  and  healthy,  its  occurrence,  like  that  of  other  acute  diseases, 
is  favoured  by  conditions  which  reduce  the  strength  and  lower  the  resist- 
ing power.  Therefore  impairment  of  health  must  be  looked  upon  as  one 
of  the  predisposing  causes  of  the  malady. 

Morbid  Anatomy. — The  morbid  processes  which  constitute  an  attack  of 
pneumonia  are  divisible  into  three  well-mai'ked  stages.  In  the  first — the 
stage  of  engorgement— there  is  congestion  of  the  capillary  vessels  which 
ramify  between  the  air-vesicles  and  on  the  minute  bronchia,  and  swelling 
of  the  alveolar  epithelium.  The  organ  is  heavier  than  natural,  and  darker 
in  tint.  It  still  contains  air,  and  therefore  crepitates  on  pressure  although 
less  perfectly  than  natural ;  l3ut  its  substance  tears  readily,  retains  the  mark 
of  the  finger,  and  on  section  pours  out  a  reddish,  frothy  fluid  from  the 
divided  surfaces. 

In  the  second  stage — the  stage  of  red  hepatisation — the  alveolar  epithe- 
lium is  swollen  and  granular.  An  exudation  of  the  constituents  of  the 
blood  coagulates  in  the  air-vesicles.  The  alveoli  and  small  air-passages 
connected  with  them  are  crowded  with  white  and  red  blood  corpuscles, 
which  distend  these  little  cavities  and  cause  complete  consolidation  of  the 
lung.  The  affected  part,  therefore,  is  airless  and  can  no  longer  crepitate. 
It  tears  with  the  utmost  ease.  Its  bulk  is  increased  ;  it  sinks  in  water ; 
and  on  section  the  surface  is  dryish  and  somewhat  granular,  although 
pressure  causes  a  thick,  turbid  fluid  to  ooze  out.  The  colour  is  reddish- 
brown,  marbled  here  and  there  with  gra}'.  Usually  the  adjacent  pleura  is 
also  inflamed.  It  is  opaque  and  congested,  and  adhering  to  it  are  patches 
of  lymph. 

In  the  third  stage — the  stage  of  gray  hepatisation — the  colour  of  the  dis- 
eased part  of  the  lung  becomes  grayish  or  whitish-yellow.  White  blood 
corpuscles  continue  to  exude  into  the  air-cells,  and  there  is  besides  prolif- 
eration of  the  alveolar  epithelium ;  so  that  with  the  microscope  we  find 


424  DISEASE   IIS^   CIIILDREX. 

epithelial  cells,  granule  cells,  and  leucocytes.  The  fibrinous  exudation  dis- 
integrates, and  the  cells  quickly  undergo  fatty  degeneration.  The  organ 
is  stni  heavy  and  aiiiess,  and  is  vei-y  soft  in  consistence,  so  that  a  little 
pressure  breaks  it  down.  The  cut  or  torn  surface  is  but  slightly  gi-anular, 
and  on  pressure  gives  out  a  pui'iform  fluid. 

These  various  stages  of  the  disease  may  usually  be  seen  to  occupy 
different  part  of  the  lung  at  the  same  time  ;  for  as  the  disease  spreads  from 
one  part  of  the  organ  to  another,  it  is  far  more  advanced  in  the  part  fii'st 
attacked.  The  extent  of  tissue  involved  is  subject  to  great  variety.  The 
affection  may  be  hmited  to  a  small  patch,  or  may  involve  a  vrhole  lobe,  or 
even  the  entire  lung.  It  attacks  the  base  by  preference,  but  is  far  from 
uncommon  at  the  apex,  esj)ecially  in  the  child.  Usually  the  consolidation 
is  confined  to  one  side  of  the  chest ;  but  double  pneumonia  is  said  to  be 
more  common  in  children  than  in  adults. 

The  process  of  resolution  in  .the  affected  part  consists  in  a  fatty  degen- 
eration and  liquefaction  of  the  contents  of  the  alveoh  and  small  aii'-tubes. 
Thus  softened  and  hc[uefied  the  inflammatory  products  are  readily  absorbed 
or  coughed  up ;  the  au--ceUs  are  freed ;  and  the  circulation  through  the 
capillaries  ramifying  on  the  alveolar  partitions  is  restored.  Eesolution  is 
the  normal  and  favourable  termination  to  a  croupous  pneumonia  ;  and  if 
the  illness  be  primary  is  the  common  ending  in  the  child.  In  exceptional 
cases,  usually  when  the  disease  is  secondaiy,  suj)puration  may  occur  with 
the  formation  of  an  abscess,  or  the  inflammatory  process  may  pass  into 
gangrene.  Still,  gangrene  is  rare  as  a  consequence  of  pneumonia;  and 
probably  never  occurs  as  a  result  of  the  imcomplicated  disease.  It  may, 
however,  follow  in  cases  where  emboli  derived  from  ante-mortem  clotting 
in  the  right  heart  are  an-ested  in  the  pulmonaiy  capillaries.  If  BouiUard's 
statement  that  a  peculiar  tendency  to  the  formation  of  such  clots  is  a 
common  feature  of  the  true  pneumonic  disease  be  con-ect,  it  is  surprising 
that  the  gangrenous  change  is  not  more  often  met  with.  Croupous  pneu- 
monia is  not  a  caixse  of  phthisis.  A  simple  unabsorbed  consohdation,  such 
as  is  common  after  cataiThal  inflammation  of  the  lung,  rarely  if  ever  results 
from  the  croupous  form  of  the  disease. 

On  account  of  the  apparent  analogy  between  pneumonia  and  the  acute 
specific  diseases,  pathologists  have  searched  carefully  amongst  the  morbid 
products  in  the  lung  for  signs  of  microscojoic  organisms,  such  as  have  been 
shown  to  exist  in  cases  of  erysipelas.  Friedlander,  of  Berlin,  in  searching 
amongst  the  fibrinous  effusions  in  the  bronchial  tubes,  and  in  examining 
sections  of  the  lung-tissue  and  inflamed  pleura,  found  in  each  of  eight 
cases  submitted  to  investigation  eUipsoidal  micrococci  which  were  coloured 
deeply  by  the  aniline  dyes.  The  organisms  were  found,  as  a  rule,  arranged 
in  pairs  or  chains  ;  but  in  some  parts  they  swai-med  in  enormous  numbers,' 
especially  in  the  interior  of  the  alveoli  and  the  lymphatic  vessels.  Koch, 
Klebs,  and  other  observers  have  also  described  similar  organisms. 

Symj-jtoms. — The  onset  of  croupous  pneumonia  is  sudden,  and  is  usually 
marked  by  signs  of  great  perturbation  of  the  nervous  system.  The  child 
is  often  convulsed,  and  the  eclamptic  seizin-es  may  succeed  one  another, 
with  only  short  intervals  of  quiet,  for  hours  together.  In  other  cases  the 
patient  complains  of  severe  headache  and  pains  about  the  chest.  He  vomits 
repeatedly  ;  shivers  or  cowers  over  the  fire  ;  and  towards  the  evening  may 
become  delirious.  From  the  fii-st  the  temperature  is  high,  the  thermometer 
marking  103°-105°,  or  a  still  greater  elevation.  From  the  first,  too,  cough 
is  noticed,  and  is  a  source  of  much  distress  from  the  pain  it  excites  in  the 
chest.     The  cough  is  characteristic.     It  assumes  the  form  of  a  short,  shai-p 


CEOUPOUS  PNEUMONIA — MOEBID  ANATOMY — SYMPTOMS.      425 

hack,  and  in  older  cliildren  may  be  accompanied  by  the  expectoration  of  a 
rusty  sputum.  The  cheeks  are  brightly  flushed  ;  the  eyes  look  heaYj,  and 
the  face  is  distressed  ;  the  nares  act ;  the  tongue  is  thickly  furred  ;  epis- 
taxis  is  a  common  symptom  ;  and  the  weakness  is  often  from  the  first  a 
notable  feature  in  the  case.  This  weakness  often  amounts  to  marked  mus- 
cular prostration.  An  infant  lies  quietly  and  takes  no  notice  of  what  goes 
on  around  him.  An  older  child  seems  stupid,  and  often  makes  no  reply  to 
questions  addressed  to  him,  as  to  do  so  requires  an  amount  of  exertion  to 
which  he  feels  himself  unequal. 

As  the  disease  goes  on  there  is  little  alteration  in  the  symptoms.  The 
child  lies  on  his  back  in  his  bed.  He  is  very  thirsty,  but  has  no  incHna- 
tion  for  food.  His  face  continues  flushed,  and  often  a  patch  of  herpes  is 
seen  on  the  upper  hp.  His  breathing  is  hurried  and  short ;  and  its  rhythm 
is  altered,  the  pause  taking  place  at  the  end  instead  of  at  the  beginning 
of  inspiration.  This  is  probably  due  to  an  effort  to  suppress  the  cough. 
The  peculiar  character  of  the  cough  has  been  already  referred  to.  It 
occurs  in  short  single  hacks,  one  to  each  short  inspiration  ;  and  these  often 
continue  until  the  child  seems  quite  exhausted. 

After  three  or  four  days  the  flush  disapjDcars  from  the  cheeks,  and  the 
face  is  left  pale,  with  a  little  lividity  about  the  eyelids  and  mouth.  The 
nervous  symptoms  also  subside,  and  the  nocturnal  delirium  rarely  lasts 
longer  than  three  or  four  nights.  Usually  the  period  of  completion  of  the 
exudation  is  marked  by  a  subsidence  of  the  more  severe  features  of  the 
case.  The  temperature  remains  elevated,  but  the  child  looks  less  dull 
and  self-absorbed ;  his  expression  of  distress  passes  away,  and  he  takes 
some  interest  in  what  is  going  on  around  him.  The  period  of  resolution 
is  marked  by  a  sudden  fall  of  the  temperature,  which  sinks  below  the  level 
of  health,  and  the  child  passes  rapidly  into  a  state  of  convalescence. 

The  more  special  symptoms  will  now  be  considered  in  detail 

Nervous  symptoms  are,  as  a  rule,  more  violent  at  the  beginning  of  the 
disease.  Convulsions  cease  after  a  few  hours,  and  although  delirium  may 
persist  for  several  nights,  it  rarely  continues  after  consolidation  has  been 
completed.  Severe  cerebral  symptoms  are  said  to  be  more  common  in 
cases  where  the  apex  of  the  lung  is  the  part  to  be  attacked,  but  they  are  not 
limited  to  such  cases  ;  indeed,  in  children  they  are  often  quite  as  marked 
when  any  other  part  of  the  lung  is  involved.  It  is  very  common  to  find  a 
pneumonia  of  the  apex  unaccompanied  by  any  sign  of  nervous  irritation  ; 
and  according  to  my  experience  inflammation  of  this  part  of  the  lung,  in 
the  large  majority  of  cases,  runs  in  the  child  an  especially  short  and  favour- 
able coTU'se. 

When  nervous  symptoms  occur  the  form  they  take  is  subject  to  con- 
siderable variety.  In  infants  there  is  usually  great  drowsiness,  preceded, 
perhaps,  by  convulsions,  and  often  accompanied  by  twitchings  of  the  facial 
muscles  and  of  the  muscles  of  the  limbs.  Sometimes  the  child  clutches  at 
his  mother's  dress  as  if  in  fear  of  falling  ;  and  when  the  drowsiness  passes 
off  he  cries  fretfully  as  if  in  pain.  In  an  older  child  severe  headache  and 
delirium  are  usually  the  most  prominent  of  the  nervous  symptoms.  Thus, 
a  little  giii,  aged  nine  years,  came  back  from  school  complaining  of  head- 
ache and  pains  in  the  chest  and  back.  For  the  next  two  days  she  vomited 
repeatedly,  groaned  with  the  pain  in  her  head,  and  was  delirious  at  night, 
lying  with  her  head  back  and  her  arm's  up  to  her  forehead.  There  was  no 
squint ;  her  nose  bled  once,  and  she  coughed  and  expectorated  phlegm 
streaked  with  blood.  The  child  was  seen  at  the  hospital  three  days 
afterwards.     Her  temperature  was  then  (6  p.m.)  103°,  and  there  was  con- 


426  DISEASE  11!^  CHILD re::^. 

solidation  of  the  lower  two-thirds  of  the  left  lung  on  the  posterior  as- 
pect. 

In  many  cases  where  nervous  symptoms  are  prominent  there  is  a  sallow 
tint  of  the  face,  with  tenderness  over  the  Uver,  and  a  constijDated  state  of 
the  bowels.  The  symj)toms  of  nervous  excitement  do  not  a]3j)ear  to  be 
dependent  upon  undue  elevation  of  temperatiu'e,  for  they  do  not  neces- 
sarily occur  in  cases  where  the  pyrexia  is  most  marked  ;  nor  do  they  seem 
to  have  any  connection  with  the  ordinary  reflex  excitability  of  the  nervous 
system  so  common  in  the  young  child. 

A  little  girl,  aged  three  years,  was  noticed  to  be  very  restless  and  irri- 
table for  a  fortnight.  At  the  end  of  that  time  she  had  a  lit  while  at  dinner. 
The  child  was  brought  to  the  hosj^ital  and  remained  convulsed  for  two 
hours.  She  was  kept  in  the  hospital  for  about  a  week,  on  account  of 
twitchings  in  the  muscles  and  a  certain  excitability  of  manner,  although 
she  had  no  return  of  the  fits  and  seemed  to  be  perfectly  intelligent.  The 
bowels  were  costive  and  had  been  much  confined,  otherwise  no  derange- 
ment of  organs  could  be  discovered.  After  her  discharge  the  child 
remained  well  for  a  fortnight,  and  was  then  brought  back  to  the  hospital 
with  an  attack  of  lobar  pneumonia  invohing  the  lower  part  of  the  right 
lung.  In  this  attack,  although  the  temperature  was  high  (about  104°,  both 
morning  and  evening)  the  illness  had  not  been  ushered  in  by  convulsions  ; 
there  was  complete  absence  of  nervous  excitement  ;  and  the  disease  ran 
an  exceptionally  mild  course. 

The  breathing  in  pneumonia  is  hui-ried  from  the  first.  There  is  no 
actual  dysj)noea,  for  in  an  ordinary  case  we  find  none  of  the  distress  which 
is  seen  when  a  child  is  consciously  suffering  from  shortness  of  breath.  He 
lies  down  in  his  bed  and  requires  no  support  by  additional  pillows.  The 
nares  dilate  widely,  but  the  respiratory  movements  are  merely  increased 
in  rapidity  without  being  exaggerated  in  degree.  The  pulse  is  also  quicker 
than  normal,  but  is  proportionately  less  hurried  than  the  breathing.  Con- 
sequently there  is  a  disturbance  of  the  relation  naturally  existing  between 
the  pulse  and  the  resjDiration  which  is  a  ^exj  important  symptom.  The 
ratio  from  being  1  to  3.5  is  reduced  to  1  to  2.5  or  even  1  to  2.  Thus, 
a  respii'atory  rate  of  75  with  a  pulse  rate  of  IttO  is  very  commonly  met 
with.  Although  the  rapidity  of  breathing  is  not  accompanied  under  ordi- 
nary circumstances  by  a  feeling  of  dyspnoea,  the  child  shows  by  his  man- 
ner that  the  supjDly  of  air  to  his  lungs  is  a  pressing  necessity,  for  he  will 
not  willingly  allow  the  process  to  be  interrupted.  He  will  bear  much  dis- 
comfort without  complaint,  and  indeed  the  passiveness  of  a  young  child 
under  examination  is  a  characteristic  feature  of  the  disease.  If  he  begin 
to  cry  he  usually  ceases  to  do  so  very  quickly.  If  he  suck,  he  does  so 
hurriedly,  stopping  at  short  intervals  to  breathe  thi'ough  his  half-open 
mouth,  as  air  cannot  be  admitted  in  sufficient  quantity  through  the  nose. 

The  tongue  is  thickly  furred,  and  in  severe  cases  may  become  dry  and 
brown.  Vomiting  often  occui's  at  the  beginning.  The  bowels  are  usually 
confined,  but  may  be  loose,  and  in  exceptional  cases  there  is  profuse  diar- 
rhoea.    The  appetite  is  completely  lost,  and  there  is  great  thii'st. 

The  urine  is  diminished  in  quantity.  Its  specific  gravity  is  high,  and 
it  is  often  thick  with  lithates.  The  excretion  of  urea  and  uric  acid  is 
above  the  average  of  health  ;  but  there  is  a  great  diminution  in  the  amount 
of  chlorides ;  and  at  the  height  of  the  disease  these  salts  may  disajDpear 
altogether  from  the  urine.  Occasionally  there  is  albuminuria  ;  and  bile 
pigment  is  often  noticed. 

The  pyrexia  is  high  from  the  first,  and  the  remission  in  the  morning  is 


CKOUPOUS   PNEUMONIA — SYMPTOMS.  427 

often  very  slight,  seldom  exceeding  a  degree  or  a  degree  and  a  half.  The 
temperature  rises  usually  to  between  103°  and  105°,  but  may  be  higher. 
It  often  reaches  its  maximum  on  the  third  day.  When  the  temperature 
falls  it  falls  suddenly.  Thus,  in  the  case  of  a  little  girl,  aged  five  years, 
on  the  evening  of  the  fifth  day  the  thermometer  registered  104.2°.  It  then 
began  to  fall.  At  10  p.m.  it  was  101.2°  ;  at  2  a.m.  on  the  following  morning 
it  was  100.2°  ;  and  at  6  a.m.  99°.  It  remained  all  day  at  this  level,  being  the 
same  at  10  p.m. 

Although  in  ordinary  cases  of  pneumonia  there  is  no  actual  dyspnoea, 
in  exceptional  instances  we  find  serious  suffering  from  want  of  breath.  It 
occasionally  happens  that  when  a  large  area  of  lung  has  become  rapidly 
consolidated  the  heart's  action  is  seriously  embarrassed  by  the  impediment 
to  the  pulmonary  circulation.  The  over-distended  right  ventricle  labours 
violently  to  force  the  circulation  onwards  ;  but  its  walls  soon  become 
weakened  and  dilated  by  the  pressure  to  which  they  are  exposed.  We 
find  the  child  propped  up  in  his  cot  struggling  for  breath  with  a  pale  or 
livid  face.  His  nares  dilate  widely  at  each  inspiration  ;  the  chest-walls  are 
forcibly  elevated,  but  expand  only  imperfectly  ;  and  there  is  great  recession 
of  the  suprasternal  notch,  the  intercostal  spaces,  and  the  epigastrium  as 
each  breath  is  drawn.  The  child  can  hardly  speak,  but  his  expression  in- 
dicates terror  and  distress,  and  beads  of  sweat  often  stand  upon  his  brow. 
On  inspecting  the  chest  the  right  auricle  can  usually  be  seen  beating  in 
the  second  and  third  interspaces  to  the  right  of  the  sternum  ;  the  heart's 
action  is  violent,  while  the  pulse  at  the  wrist  is  so  feeble  as  to  be  hardly 
perceptible.  There  is,  indeed,  little  blood  in  the  systemic  circulation,  but 
the  pulmonary  system  is  engorged.  These  cases  are  not  so  common  in  the 
child  as  they  are  in  the  adult  ;  but  they  are  occasionally  met  with  in  early 
life,  and  unless  prompt  assistance  be  rendered  may  quickly  prove  fatal. 

A  physical  examination  of  the  chest  may  not  at  first  discover  any  signs 
of  the  inflammatory  lesion  in  the  lung.  Often  two  or  thi'ee  days  elapse 
before  any  characteristic  changes  are  to  be  discovered  by  the  finger  or  the 
ear.  Usually  on  the  first  day  or  two  the  percussion-note  is  normal,  and 
with  the  stethoscope  we  find  merely  a  sonoro-sibilant  rhonchus  scattered 
more  or  less  widely  over  the  lung.  Even  when  consoUdation  occurs,  if 
this  be  situated  in  the  middle  of  a  lobe,  we  may  find  bronchial  breathing, 
with  a  puff  of  fine  crepitation  at  the  end  of  inspiration,  but  the  percussion- 
note  may  be  normal  as  long  as  a  thin  layer  of  healthy  lung-tissue  intervene 
between  the  diseased  spot  and  the  surface. 

In  an  ordinary  case  the  physical  signs  of  the  disease  are  as  follows  : 

During  the  stage  of  engorgement  inspection  can  seldom  discover  any  im- 
pairment of  movement  on  the  affected  side.  In  young  children  this  is 
always  difficult  to  detect,  for  the  respiration  being  chiefly  diaphragmatic, 
the  chest-walls  take  a  comparatively  small  part  in  the  respiratory  move- 
ment. There  may  be  at  first  no  dulness  on  percussion,  or  the  note  may 
have  a  slightly  higher  pitch  than  that  over  the  sound  lung.  Tlie  breathing 
is  very  harsh  and  rather  louder  than  natural,  and  towards  the  termination 
of  this  stage  a  fine  puff  of  crepitation  is  caught  at  the  end  of  inspiration. 
This  is  usually  only  to  be  heard  when  the  child  draws  a  deep  breath.  In 
ordinary  breathing  there  may  be  a  little  coarse  bronchitic  rhonchus  both 
with  inspiration  and  expiration  which  presents  nothing  characteristic. 

In  the  stage  of  hepatisation  a  faint  vocal  vibration  may  be  sometimes 
detected  over  the  affected  side  when  the  child  speaks  or  cries.  This  sign 
is  a  very  capricious  one.  It  may  be  noticed  in  very  young  subjects  and  be 
absent  in  a  much  older  child.     If  present,  it  is  a  sign  of  value,  but  no 


428  DISEASE   IN   CHILDREN. 

infereBce  can  be  drawn  if  it  fail  to  be  perceived.  The  percussion-n^^.V, 
over  the  affected  part  is  now  dull ;  but  the  dulness  is  far  from  being 
complete,  as  in  pleurisy.  The  sense  of  resistance,  too,  although  increased, 
is  not  extreme,  as  in  the  case  of  effusion.  It  is  rather  greater  than  natural, 
and  that  is  all.  In  babies  and  young  children  the  increase  of  resistance 
may  be  very  trifling.  Auscultation  over  the  consolidated  spot  discovers  a 
loud  tubular  breath-sound,  and  the  crepitation,  which  was  before  heard  at 
the  end  of  inspiration,  is  now  no  longer  to  be  perceived,  although  at  the 
borders  of  the  solidified  region  it  may  still  be  detected.  If  the  child  can 
be  persuaded  to  speak,  the  resonance  of  the  voice  is  high-pitched  and 
sniffling,  and  is  conducted  Avith  much  greater  distinctness  than  natural  to 
the  ear.  This  sign  is,  hoAvever,  not  always  present,  and  in  a  case  of  un- 
doubted consohdation  tlie  resonance  of  the  A-oice  may  be  normal.  Indeed, 
in  exceptional  cases — owing  possibly  to  plugging  of  a  tube  with  mucus — ■ 
vocal  resonance,  and  even  blowing  breathing  itself,  may  be  indistinct  and 
distant-sounding,  or  even  altogether  supjDressed.  On  the  other  hand,  if  the 
consohdated  spot  is  in  the  middle  of  a  lobe,  comjjletely  surrounded  by 
healthy  tissue,  and  the  patient  be  an  infant,  a  bronchoi:)honic  resonance  of 
the  cry  may  be  the  only  sign  to  be  detected  of  the  puhnonary  lesion. 

When  remlution  occurs  in  the  affected  part,  crepitation  returns,  coarser 
and  more  like  bubbhng  than  before ;  the  breath-sound  becomes  less  high-^ 
jjitched  and  metallic,  and  gradually  loses  its  blowing  cpality.  The  dulness 
also  diminishes  and  finally  disappears.  Keturning  crepitation  is  often 
absent  in  the  child,  and  resolution  frequently  takes  place  without  any 
moist  rhonchus  being  heard.  The  excessive  resonance  of  the  voice  and  cry 
usually  persist  OA^er  the  affected  spot  for  some  time,  or  until  the  consolida- 
tion has  completely  disappeared.  Eesolution  is  carried  on  more  rapidly  in 
some,  children  than  in  others.  In  many  cases,  however,  when  dulness  per- 
sists for  some  weeks  after  subsidence  of  the  general  symptoms,  the  impair- 
mer/i  of  the  percussion-note  is  due  to  a  layer  of  lymph  over  the  pleui-a  at 
the  affected  spot. 

The  physical  signs  just  described  usually  occupy  the  lower  two-thii'ds 
of  one  side  ;  but  may  be  found  at  any  part  of  the  lung.  Often  they  are 
confined  to  the  apex  ;  or  may  be  discovered  OA^er  a  limited  area  under  one 
of  the  arms.  As  has  been  akeady  obserA^ed,  they  are  often  slow  to  de- 
velope  ;  and  therefore,  when  from  the  general  symptoms  croupous  pneu- 
moina  is  suspected,  frequent  and  complete  examination  should  be  made 
xmtil  the  situation  of  the  local  lesion  is  discovered.  An  important  pecu- 
liarity of  this  form  of  disease  is  that  the  physical  signs,  unless  situated  at 
the  apex  of  the  lung,  are  usually  confined  to  one  aspect  of  the  chest.  If 
they  are  detected  at  the  posterior  aspect,  the  signs  are  normal  in  front ; 
while  inflammation  of  the  anterior  part  of  the  lung  produces  no  alteration 
of  resonance  or  respiratory  sound  at  the  back  of  the  chest.  Therefore  a 
complete  examination  of  the  chest  must  be  made  before  we  are  justified  in 
saying  that  no  signs  of  pneumonia  are  present. 

Terminations. — In  the  large  majority  of  cases  in  the  child  croupous 
pneumonia  ends  in  resolution  and  recovery.  In  the  primary  form  of  the 
disease  an  unfavourable  termination  is  very  rare ;  and  even  in  cases  of  sec- 
ondary pneumonia,  unless  the  child  be  a  new-born  infant  or  in  a  state  of 
great  AA^eakness,  it  is  exceptional  for  him  to  die.  When  death  takes  place 
it  usually  occurs  on  the  fourth  or  fifth  day  as  a  result  of  failxu-e  of  the 
heart.  It  may,  however,  happen  later  as  a  consequence  of  abscess  or 
gangrene  of  the  lung. 

When  resolution  occm-s,  the  improvement  is  very  sudden,  and  the  dis- 


CROUPOUS   PNEUMONIA — SYMPTOMS.  429 

ease  terminates  by  crisis.  The  temperatui-e,  which  had  given  little  or  no 
sign  of  reduction,  falls  suddenly  in  the  course  of  twelve  houi's  to  the  normal 
level,  and  remains  low  for  four-and-twenty  hours,  even  if  it  afterwards 
undergo  a  moderate  increase.  The  crisis  often  occurs  on  the  fifth  day, 
but  may  be  defeiTed  until  the  eighth  or  ninth,  and  in  rare  cases  until 
later.  The  violence  of  the  onset,  the  height  of  the  fever,  and  the  severity 
of  the  nervous  symptoms  are  not  in  j)i'oportion  to  the  extent  of  surface  in- 
volved, nor  ai'e  they  to  be  taken  as  an  indication  that  the  course  of  the 
disease  will  be  prolonged ;  for  cases  in  which  the  general  symptoms  are 
very  pronounced  may  come  to  an  end  on  the  fifth  day.  The  cessation  of 
the  pyrexia  is  followed  by  an  immediate  improvement  in  the  child's  con- 
dition. The  skin  becomes  moist ;  the  tongue  cleans ;  the  pulse  and  respi- 
ration fall  in  frequency  and  regain  their  normal  relation  to  one  another  ; 
the  cough  is  loose  and  less  frequent ;  the  uiine  is  more  profuse  ;  and  the 
appetite  returns.  The  favourable  change  in  the  general  symptoms  precedes 
the  improvement  in  the  physical  signs,  and  for  a  day  or  two  the  resonance 
may  continue  to  be  impaired,  and  the  breathing  to  be  bronchial  or  blow- 
ing over  the  affected  part  of  the  lung. 

In  exceptional  cases  the  termination  by  resolution  occurs  m»re  gradu- 
ally. The  temperature  perhaps  falls  suddenly,  but  almost  immediately 
rises  again  ;  so  that  for  two  or  three  days,  a  week,  or  even  longer,  the 
bodily  heat  may  continue  to  be  considerable  at  night,  with  a  morning  fall. 
Sometimes,  after  remaining  low  for  two  or  three  days  the  thermometer 
again  registers  a  high  degree  of  temperature  and  the  child  passes  through 
a  complete  relapse  of  his  illness.  The  relapse  is,  however,  usually  shorter 
and  less  severe  than  the  original  attack. 

The  termination  by  abscess  of  the  lung  is  not  often  seen  except  in  cases 
where  the  pulmonary  affection  is  secondary  to  pyaemia.  It  does,  however, 
occasionally  occur  in  children  of  weakly  constitution  who  are  living  in 
thoroughly  insanitary  conditions ;  and  may  also  be  seen  in  cases  where  in- 
flammation is  set  up  in  the  lung  as  a  consequence  of  impaction  of  a  foreign 
body  in  one  of  the  bronchi. 

When  abscess  of  the  lung  occurs  in  a  case  of  secondary  pneumonia  the 
temperatui-e  remains  high,  or  if  it  fall,  rapidly  rises  again  and  assumes  a 
hectic  type  ;  there  is  great  weakness  ;  the  tongue  becomes  dry  and  brown, 
and  the  complexion  dull  and  earthy  in  tint,  with  Uvid  discolouration  of  the 
eyelids  and  lips.  On  examination  of  the  chest  the  dulness  is  found  to  per- 
sist, and  the  breathing  to  be  bronchial  or  blowing,  with  much  large  bub- 
bling or  even  metallic  rhonchus.  Unless  the  abscess  burst  into  a  bronchial 
tube,  and  its  contents  be  evacuated,  the  physical  signs  are  not  characteris- 
tic of  the  lesion.  If,  however,  the  puinilent  contents  are  discharged,  caver- 
nous breathing,  whispering  bronchophony,  and  the  usual  signs  of  a  cavity 
may  be  detected  at  the  seat  of  the  disease.  If  the  abscess  be  the  result  of 
pysemic  infection,  the  general  symptoms  are  those  of  the  constitutional 
state,  and  the  local  signs,  not  being  the  consequence  of  any  extensive  local 
inflammation,  may  be  overlooked,  more  especially  as  the  abscesses  are  small 
and  are  often  completely  surrounded  by  healthy  lung-tissue. 

Gangrene  of  the  lung  will  be  considered  in  a  separate  chapter. 

Pneumonia  is  occasionally  latent.  This  form  of  the  disease  is  most 
commonly  seen  when  the  patient  is  a  young  child  worn  and  wasted  by 
chronic  abdominal  derangement,  whose  nervous  iiTitabihty  is  almost  com- 
pletely lost.  In  such  cases  the  oi-dinary  symptoms  of  invasion  are  not  no- 
ticed. There  is  no  sign  of  pain  in  the  chest.  Even  the  cough  may  be 
infrequent  or  absent.     A  slight  rise  in  the  temperature,  increased  rapidity 


430  DISEASE   IIN^    CHILDEEI^. 

of  breathing,  perversion  of  the  pulse-respiration  ratio,  and  indications  of 
early  prostration  may  be  the  only  symptoms  excited  by  the  intercurrent 
malady. 

Complications. — Inflammation  of  neighbouring  tissues  often  complicates 
a  case  of  pneumonia.  In  the  child  a  certain  amount  of  bronchitis  is  a  com- 
mon feature  of  the  illness.  In  almost  all  cases  we  can  detect  some  sonoro- 
sibilant  rhonchus  not  only  in  the  affected  lung  but  also  on  the  opposite 
side  of  the  chest.  In  many  instances  there  is  also  some  moist  rhonchus. 
As  a  rule  the  amount  of  bronchitis  is  trifling,  and  the  comphcation  is  rarely 
sufiiciently  marked  to  be  a  source  of  danger. 

Plastic  pleurisy  may  also  accompany  the  pulmonary  inflammation,  and 
sometimes  there  is  a  moderate  liquid  effusion.  The  jDleurisy  is  seldom  of 
much  moment,  and  absorj)tion  usually  occurs  rapidly  when  resolution  of 
the  inflammation  has  taken  place.  As  has  been  before  remarked,  the  per- 
sistence of  dulness  over  the  seat  of  disease  during  convalescence  is  com- 
monly due  to  the  presence  of  a  layer  of  lymph  upon  the  pleural  lining  of 
the  chest. 

Pericarditis  is  sometimes  induced  by  extension  of  the  inflammation  ; 
but  this  -complication  is  less  common  in  pneumonia  than  in  the  case  of 
pleurisy.  In  the  child  the  inflammation  of  the  j)ericardium,  when  it  occurs 
in  the  course  of  a  croupous  pneumonia,  is  usually  plastic,  and  is  but  rarely 
accompanied  by  effusion.  In  regard  to  prognosis  it  is  probably  of  small 
importance. 

Jaundice  is  sometimes  seen,  and  is  usually  mild.  It  is  due  to  pressure 
upon  the  bile-ducts  by  hypersemic  portal  vessels,  the  circulation  through 
the  liver  being  impeded  owing  to  the  condition  of  the  lung.  It  may  also 
arise  from  gastro-duodenal  catarrh.  If  this  be  sufficiently  intense  to  create 
an  impediment  to  the  introduction  of  nourishment,  the  consequences 
may  be  serious.  Gastric  or  intestinal  catarrh  may  be  jDi'esent  without 
jaundice.  Diarrhoea  is  a  symptom  not  unfrequently  seen  at  the  begin- 
ning of  an  attack  of  pneumonia.  As  a  rule,  the  purging  is  not  excessive, 
and  iU  consequences  rarely  foUow  from  the  intestinal  derangement. 

Diagnosis.— hx  a  well-marked  case  of  croupous  pneumonia  the  diag- 
nosis is  not  difficult.  The  sudden  occurrence  of  high  fever,  headache,  pain 
in  the  side,  short  hacking  cough,  perverted  pulse-respiration  ratio,  and 
rapidly  increasing  muscular  weakness  is  very  suggestive  of  this  disease. 
It  is  important  to  bear  in  mind  the  nervous  symptoms  which  often  accom- 
pany the  onset  of  the  illness,  or  we  may  alarm  ourselves  with  suspicions  that 
an  inflammatory  head  affection  is  about  to  manifest  itself.  But  although 
a  feverish  child  is  often  light-headed  at  night,  and  wanders  somewhat 
in  his  talk,  high  fever  with  early  and  marked  delirium  is  not  a  common 
occurrence;  indeed,  this  combination  breaking  in  upon  a  state  of  health,  if 
combined  with  a  short  hacking  cough,  is  almost  peculiar  to  jDneumonia. 
If,  in  addition,  we  notice  that  the  nares  dilate  at  each  inspiration,  and  that 
the  breathing  is  quickened  out  of  proportion  to  the  jDulse,  we  are  justified 
in  entertaining  the  strongest  suspicions  that  the  attack  is  one  of  croupous 
inflammation  of  the  lung. 

In  some  cases  cough  is  absent,  or  is  so  slight  that  it  passes  quite  unno- 
ticed, and  the  nares  are  motionless  in  inspiration.  StiU,  the  sudden  occur- 
rence of  a  high  temperature,  with  pungent  heat  of  skin,  as  estimated  by 
the  hand,  combined  with  early  delirium,  should  suggest  the  presence  of 
pneumonia.  In  all  such  cases  the  chest  should  be  minutely  examined  for 
confirmatory  evidence.  It  must  be  remembered  that  the  physical  signs  are 
often  slow  to  appear,  and  that  forty-eight  houi-s,  or  even  three  or  foui-  days, 


CROUPOUS    PNEUMONIA — DIAGNOSIS — PEOGNOSIS.  431 

may  pass  without  any  consolidation  of  tlie  lung  being  discovered.  It  must 
also  be  remembered  that  the  severity  of  the  symptoms  is  not  in  proportion 
to  the  extent  of  lung-tissue  involved,  and  that  after  a  violent  onset  the 
local  signs  may  be  confined  to  a  mere  patch  of  solidification  at  any  part  of 
the  pulmonary  surface.  We  must  not,  therefore,  content  ourselves  with  a 
cursory  examination  of  the  bases  of  the  lungs.  Careful  attention  must 
also  be  directed  to  the  apices,  and  we  must  not  forget  to  search  the  axillae 
on  either  side  for  evidence  of  disease.  In  cases  of  pneumonic  consoli- 
dation the  dulness  is  not  complete,  and  is  accompanied  by  Httle  increase 
in  resistance.  Moreover,  in  the  large  majority  of  cases  the  signs  are 
limited  to  one  aspect  of  the  chest.  Sometimes  a  faint  vibration  of  the 
chest-wall,  inappreciable  upon  the  healthy  side,  may  be  detected  over  the 
seat  of  disease  when  the  child  speaks  or  cries. 

The  combination  of  high  fever,  headache,  and  diarrhoea  may  be  per- 
plexing. If  the  patient  be  an  infant,  the  symptoms  may  be  ascribed  to 
teething,  and  the  condition  of  the  lung  may  be  overlooked.  The  nares, 
however,  act,  and  the  respiration,  if  counted,  will  be  found  to  be  hurried 
out  of  proportion  to  the  pulse.  If  a  j^hysical  examination  be  made,  as  it 
ought  to  be,  a  matter  of  routine,  the  nature  of  these  cases  will  not  escape 
recognition.  In  an  older  child  the  same  combination  of  symptoms  Avould 
suggest  enteric  fever.  But  the  violent  onset,  the  flushed  cheeks,  the  active 
nares,  the  rapid  breathing,  the  hacking  cough,  are  very  unlike  the  begin- 
ning of  enteric  fever  ;  and  if  delirium  come  on,  it  begins  very  early  (on 
the  first  or  second  day)  in  pneinnonia,  while  in  typhoid  fever  it  is  rarely 
seen  before  the  end  of  the  first  week. 

In  young  children,  in  whom  the  disease  may  begin  with  violent  convul- 
sions, or  with  a  drowsiness  ap]Droaching  to  stupor,  the  diagnosis  is  very 
(difficult,  esjDecially  as  there  is  often  no  cough.  Usually  until  signs  of  con- 
solidation are  discovered  at  some  part  of  the  chest  the  nature  of  the  illness 
must  remain  doubtful  Still,  drowsiness  and  a  temperature  of  103°  or 
104°,  without  signs  of  severe  headache,  but  with  rapid,  regular,  breathing, 
a  perverted  pulse-respiration  ratio,  and  pungent  heat  of  skin  should  suggest 
the  presence  of  pneumonia. 

In  the  latent  form,  which  usually  occurs  in  wasted  children,  rapid  breath- 
ing and  active  nares  ought  always  to  lead  us  to  make  careful  and  repeated 
examination  of  the  chest. 

The  distinguishing  marks  of  catarrhal  pneumonia  and  collapse  of  the 
lung  are  considered  in  the  chapters  treating  of  those  subjects. 

Prognosis. — Primary  croupous  pneumonia,  unless  very  extensive,  almost 
always  terminates  favourably,  and  even  in  infants  is  seldom  dangerous. 
Resolution  takes  place  early,  as  a  rule,  and  the  consolidation  clears  com- 
pletely away,  leaving  the  lung  as  sound  as  before.  The  situation  of  the 
local  lesion  has  no  influence  upon  the  prognosis,  and  no  special  danger  is 
connected  with  inflammation  of  the  apex  of  the  lung.  The  nervous  sj^mp- 
toms,  however  serious  they  may  appear,  need  cause  no  alai-m,  for  they  sub- 
side altogether  when  consolidation  becomes  estabhshed.  Delirium  in  itself, 
without  oth^r  signs  of  nervous  disturbance,  is  rarely  an  unfavourable  symp- 
tom in  a  feverish  child.  It  usually  disappears  after  a  few  days,  but  may 
return  again  towards  the  end  of  the  disease  as  a  result  of  weakness  ;  but 
this  recurrence,  if  the  indication  which  it  furnishes  is  attended  to,  is  rarely 
followed  by  dangerous  consequences. 

The  secondary  forms  of  pneumonia  are  more  serious  than  the  primary, 
for  the  tendency  to  failure  of  the  heart's  action  is  increased  by  weakness 
induced  by  previous  disease.     So,  also,  the  existence  of  a  depressing  com- 


432  DISEASE  IIT   CHILDKE]^". 

plication  adds  to  the  danger  of  the  ease.  Pneumonia  occurring  in  the 
coiu'se  of  Bright's  disease  is  an  especially  serious  form  of  the  complaint. 

A  very  rapid  pulse  (over  140)  is  an  unfavourable  sign,  especially  if 
the  pulsations  are  irregular  in  force  and  rhythm.  So,  also,  a  rise  of 
temperature  above  105°  should  be  regarded  with  anxiety,  although  in 
early  life  this  phenomenon  is  less  serious  than  a  similar  elevation  would  be 
in  the  case  of  an  adult. 

Treatment. — In  an  ordinary  case  of  jDrimarj^  croupous  pneumonia  little 
is  requu'ed  beyond  keejiing  the  child  quiet  in  bed  in  a  well  ventilated 
room,  wrapping  the  affected  side  of  the  chest  in  cotton  wool  or  linseed 
meal  poultices  frequently  renewed,  and  administering  a  simple  effervescing 
sahne  or  other  febrifuge  draught  several  times  in  the  day.  The  pain  in 
the  side  is  usually  greatly  relieved  by  the  use  of  hot  poultices  and  other 
apphcations.  To  be  ef&cient,  however,  these  should  be  used  as  hot  as  the 
skin  can  bear  them  ;  and  dry  heat,  such  as  a  bag  filled  with  heated  bran  or 
salt,  is  perhaps  better — it  is  certainly  more  manageable — than  hot  flannels. 
If  any  severe  pain  is  comjijlained  of,  a  proportion  of  mustard  (one-fifth  or 
one-sixth)  may  be  added  to  the  poultice,  and  this  may  be  allowed  to  remain 
for  six  or  eight  hours  in  contact  with  the  skin.  If  the  cough  is  distressing 
a  few  drops  of  ipecacuanha  wine  and  of  compound  tincture  of  camphor 
may  be  included  in  the  mixture  ;  and  a  few  drops  of  antimonial  wine  may 
be  added  with  advantage  on  account  of  its  diaphoretic  action  upon  the 
skin.  The  old  plan  of  attempting  to  reduce  the  inflammation  by  large 
doses  of  antimony  is  one  to  be  very  strongly  deprecated.  If  the  bowels 
are  confined,  or  the  complexion  has  a  sallow  cast  and  there  is  tenderness 
over  the  hver,  an  aperient  powder  should  be  prescribed,  such  as  a  grain  of 
calomel  with  two  or  three  grains  of  jalapine  ;  but  the  aperient  seldom  re- 
quires repetition.     Violent  purgation  in  this  disease  is  decidedly  injurious. 

The  diet  should  consist  of  meat  broths  and  milk  until  the  consolidation 
is  complete.  When  the  establishment  of  blowing  breathing  and  the  dis- 
appearance of  crej)itation  show  that  the  process  of  repair  is  about  to  begin 
the  diet  can  be  imj)roved.  Strong  beef-tea  should  then  be  given  at  proper 
intervals,  and  a  yolk  of  egg  may  be  added  to  the  diet.  The  thirst  may 
be  relieved  as  often  as  the  child  requires  drink,  but  he  must  not  be 
allowed  to  take  a  large  quantity  of  fluid  at  one  time.  In  the  case  of  an 
infant  at  the  breast,  or  one  who  is  brought  up  by  hand,  some  thin  barley- 
water  should  be  given  from  time  to  time  to  reheve  thirst,  so  that  the 
quantity  of  food  tlie  child  takes  may  be  restricted. 

If  the  pyrexia  rise  to  a  high  level  and  the  child  seem  distressed  by  the 
intensity  of  the  fever,  the  temperature  may  be  reduced  by  sponging  the 
surface  of  the  body  with  tepid  water  ;  or  if  absolutely  necessary,  the  child 
may  be  placed  in  a  tepid  bath  of  the  temperature  of  70°.  If,  however,  the 
bath  be  used,  great  cai'e  must  be  taken  not  to  depress  the  child,  as  failure 
of  the  heart's  action  is  one  of  the  dangers  to  be  apprehended  in  cases  of 
pneumonia.  Both  before  immersion  and  after  removal  from  the  bath  a 
stimidant  shovdd  be  given,  and  if  the  feet  feel  cold,  a  hot  bottle  should  be 
put  into  the  bottom  of  the  cot.  Quinine  is  strongly  I'ecomm ended 
by  some  authors  as  a  valuable  remedy  at  an  early  jDcriod  of  the  illness. 
It  is  given  partly  as  an  anti-pyretic,  for  it  is  said  quickly  to  reduce  the 
temperature  without  weakening  the  heart ;  partly  for  its  supposed  influence 
in  checking  the  spread  of  the  disease  over  the  lung.  To  be  of  service  as 
an  anti-pyretic  the  drug  must  be  given  in  full  doses  ;  and  it  must  be 
remembered  that  children  bear  the  remedy  well.  For  an  infant  of  twelve 
months    one    grain    should  be  administered   three  times  a  day.      This 


CEOUPOUS   PNEUMONIA — TEEATMENT.  433 

quantity  can  be  increased  by  one  grain  and  a  half  for  every  year  of  tbe 
child's  life.  Aconite  and  other  depressing  anti-pyretic  drugs  are  dangerous 
remedies  to  employ  in  cases  of  pneumonia  on  account  of  their  weakening 
influence  on  the  heart. 

In  cases  where  great  dyspnoea  and  threatened  cardiac  failure  arise  from 
over-distention  of  the  right  side  of  the  heart,  it  becomes  a  serious  question 
whether  abstraction  of  a  small  quantity  of  blood  is  not  called  for.  If  the 
danger  is  imminent  I  should  not  hesitate  to  take  one,  two,  or  more  ounces 
of  blood  from  the  arm.  Life  can  often  be  saved  by  this  means.  Even 
while  the  blood  is  flowing  the  inspirations  become  slower  and  quieter  and 
expand  the  chest  more  fully  ;  the  pulse  gains  in  fulness  and  force  ;  and 
the  anxiety  and  feeling  of  oppression  subside.  I  can  look  back  upon 
several  fatal  cases  which  I  now  believe  might  have  been  saved  had  I  had 
the  courage  to  relieve  the  labouring  heart  by  the  judicious  removal  of 
blood.  It  is  in  such  cases  alone  that  bleeding  is  justifiable  in  this  disease  ; 
and  here  the  treatment  is  directed  not  against  the  inflammation,  but  against 
one  of  its  consequences,  viz.,  the  overtaxing  of  the  heart  by  the  impedi- 
ment to  the  pulmonary  circulation. 

It  is  not  often  that  stimulants  are  required  in  cases  of  primary  pneu- 
monia in  children,  but  if  the  disease  is  secondary  they  may  have  to  be 
resorted  to.  Great  rapidity  of  the  pulse  is  an  indication  for  stimulants 
which  must  not  be  disregarded  ;  and  if  a  pulse  of  140  is  found  to  be  inter- 
mittent in  force  and  rhythm,  doses  of  egg-and-brandy  should  be  given  at 
regular  intervals  until  improvement  occurs. 

Delirium  at  the  beginning  of  the  disease,  if  noisy,  may  be  usually 
quieted  by  tepid  sponging  of  the  surface  of  the  body.  If  necessary,  a 
small  dose  of  Dover's  powder  can  be  given  at  night.  Chloral,  on  account 
of  its  depressing  efiect,  must  not  be  used.  If  delirium  occur  later  in  the 
illness  it  is  a  sign  of  debility,  and  energetic  stimulation  will  be  required. 
Sleeplessness  can  also  be  usuallj^  removed  by  tepid  sponging  in  the  evening. 

If  diarrhoea  occur,  it  may  often  be  promptly  checked  by  a  dose  of  castor- 
oil  or  of  rhubarb  (gr.  iij.-v.),  with  double  the  quantity  of  the  aromatic  chalk 
powder  given  every  night.  Astringents  are  rarely  necessary  in  these  cases  ; 
but  if  the  purging  continue,  sal  volatile  may  be  given  with  spirits  of 
chloroform  and  a  drop  or  two  of  laudanum,  according  to  the  age  of  the  child, 
three  or  four  times  a  day.  A  layer  of  cotton  wadding  should  be  applied 
to  the  belly  under  a  flannel  binder  for  the  sake  of  warmth ;  and  food 
should  be  given  in  small  quantities  at  a  time. 

Directly  the  temperature  falls  tonics  should  be  given ;  and  the  diet  of 
health  may  be  returned  to  ;  taking  care  that  the  food  is  digestible  in  kind^ 
and  that  it  is  given  in  quantities  suitable  to  a  convalescent. 
28 


CHAPTER  V. 

CATARRHAL  PNEUMONIA. 

Cataerhal  or  lobular  pneumonia,  or  broncho-pneumonia,  is  the  common 
form  of  inflammation  of  the  lung  met  with  in  infancy,  and  is  frequently 
seen  in  early  childhood.  The  disease  is  quite  distinct  from  the  croupous 
form  previously  described,  differing  from  it  in  its  pathology,  its  symptoms, 
and  its  tendency  to  end  in  death.  Catarrhal  pneumonia  is  nearly  always 
a  secondary  affection,  and  results  from  spread  of  inflammation  from  the 
bronchial  mucous  membrane  to  the  alveoli.  Consequently,  the  disease 
invariably  attacks  both  lungs,  although  it  may  be  more  extensive  on  one 
side  of  the  body  than  on  the  other. 

Causation. — As  broncho-pneumonia  is  always  preceded  by  pulmonary 
catarrh,  the  causes  which  induce  bronchitis  in  the  child  may  be  looked 
upon  as  tending  in  a  great  measure  to  set  up  catarrhal  pneumonia  in  the 
air-vesicles.  These  are  especially  cold  and  damp,  and  the  inhalation  of  dust 
and  other  irritating  particles  in  the  air. 

A  severe  bronchitis  in  the  young  child  always  inclines  to  spread  to  the 
finer  tubes  and  air-cells ;  but  certain  forms  of  illness  have  great  influence 
in  determining  the  extension  of  the  inflammation.  Thus,  measles  and 
whooping-cough  number  lobular  pneumonia  amongst  their  most  frequent 
sequelae,  and  the  disease  is  also  common  as  a  secondary  consequence  of 
diphtheria.  In  scrofulous  and  tubercular  subjects,  and  even  in  children 
who  are  merely  weakly  and  under-nourished,  lobular  pneumonia  is  readily 
excited.  Therefore  any  influence  which  diminishes  the  resisting  power  of 
the  child  and  lowers  his  general  health  must  be  looked  upon  as  a  predis- 
posing cause  of  the  complaint.  Thus,  bad  feeding,  insanitary  conditions, 
and  depressing  derangement  or  disease  may  all  help  to  induce  this  form  of 
pneumonia.  It  is  very  common  in  the  case  of  young  children  for  the 
illness  to  be  preceded  by  a  history  of  more  or  less  persistent  diarrhoea, 
A  young  child  who  is  subject  to  attacks  of  intestinal  catarrh  becomes 
excessively  sensitive  to  chills,  and  after  a  time  acquires  a  catarrhal  propen- 
sity which,  combined  with  the  weakness  induced  by  the  digestive  derange^ 
naent,  is  likely  to  result  in  an  attack  of  catarrhal  j)neumonia.  Neglected 
colds  on  the  chest  may  set  up  broncho-pneumonia  in  the  most  robust 
subjects;  but  amongst  the  well-to-do  classes  it  is  comparatively  rare  to  find 
this  disease  in  children  who  are  not  strumous  or  delicate,  or  rickety,  or  who 
have  not  been  lately  suffering  from  an  attack  of  measles  or  whooping- 
cough. 

Morhid  Anatomy. — Lobular  pneumonia  may  arise  as  a  consequence  of 
direct  extension  of  the  infiammation  from  the  larger  tubes  to  the  smaller, 
and  thence  to  the  air-cells;  or  may  occur  secondarily^  to  collapse  of  the 
lung.  In  the  infant  the  latter  is  the  method  in  which  the  disease  usually 
originates,  for  in  such  young  subjects,  on  account  of  the  narrowing  of  the 
bronchial  tubes,  the  feeble  inspiratory  power,  and  the  noi-mal  softness  and 


CATAERHAL   PNEUMOj^IA — MORBID   AISTATOMY.  435 

compressibility  of  the  chest-walls,  collapse  of  the  lung  is  a  very  common 
consequence  of  pulmonary  catarrh.  The  special  tendency  of  rickets  to  be 
comphcated  by  bronchitis  and  catarrhal  pneumonia  has  been  elsewhere 
referred  to.  The  difficulty  of  expanding  the  chest  in  this  disease,  owing  to 
the  softening  of  the  ribs,  greatly  contributes  to  setting  up  collapse  of  the 
lung ;  and  any  additional  impediment,  such  as  a  catarrhal  state  of  the 
bronchial  membrane,  promotes  the  exhaustion  of  the  air-cells.  Collapse  of 
the  lung  is  followed  by  congestion  of  the  small  vessels,  owing  to  the 
impediment  created  by  imperfect  aeration  of  the  blood,  and  to  the  absence 
of  the  expansion  and  contraction  of  the  au'-cells,  whose  movement  in  a  state 
of  health  materially  advances  the  pulmonary  circulation.  As  a  result  of 
congestion  of  vessels  there  is  oedema  which  causes  great  diminution  in  the 
consistence  and  cohesion  of  the  tissue  at  the  affected  spot.  In  this  state 
the  part  is  ready  for  the  development  of  inflammatory  changes.  Inflam- 
mation readily  extends  to  it  from  the  air-tubes  ;  or  the  irritation  induced 
by  the  penetration  into  it  of  secretion  from  the  bronchial  mucous  mem- 
brane excites  the  inflammatory  process. 

Lobular  pneumonia  usually  begins  in  isolated  groups  of  vesicles,  being 
often  determined  by  the  presence  in  them  of  inflammatory  products  drawn 
from  the  small  tubes  with  which  they  are  in  communication.  On  inspec- 
tion of  the  lungs  we  see  scattered  nodules  of  consolidation  of  a  reddish 
gray  colour  scattered  over  the  surface.  They  vary  in  size  from  a  small  pea 
to  a  nut.  Their  consistence  is  friable,  their  substance  smooth  or  faintly 
granular,  and  their  circumference  ill-defined.  As  the  process  advances,  the 
nodules  which  were  at  first  isolated  become  united  at  their  boi'ders  so  as  to 
produce  considerable  tracts  of  consoHdation  ;  and  at  the  same  time  the 
solidified  parts  become  firmer,  dryer,  and  of  a  yellowish  gray  colour.  In 
their  centres  we  can  sometimes  see  divided  aii'-tubes  filled  with  purulent 
matter. 

The  lung-tissue  in  which  the  nodules  are  embedded  exhibits  collapse, 
congestion,  oedema,  and  emphysema  in  various  stages  and  degrees.  A 
certain  amount  of  dilatation  of  vesicles  is  almost  invariably  present  in  the 
neighbourhood  of  collapsed  portions  of  lung,  and  there  is,  moreover,  an 
appreciable  degree  of  cylindrical  dilatation  of  all  the  minuter  bronchi, 
especially  of  those  portions  which  immediately  adjoin  the  terminal  alveoli. 
The  walls  of  these  tubes  are  excessively  attenuated.  The  dilatation  appears 
to  be  the  consequence  in  some  cases  of  accumulation  of  secretion.  In 
others  it  is  due  to  diminution  of  the  respiratory  surface,  for  plugging  of 
some  tubes  with  mucus  causes  an  increased  rush  of  air  to  the  parts  which 
still  remain  pervious. 

The  consohdating  matter  itself  consists  in  a  very  small  degree  of  ex- 
uded corpuscles,  as  in  the  case  of  croupous  pneumonia.  On  examination 
the  alveoli  will  be  found  to  be  stuffed  with  cells,  but  these  are  in  great 
part  derived  from  proliferation  of  the  epithehal  Hning  of  the  vesicles.  Mixed 
up  with  these  epithelial  elements  are  leucocytes  and  much  gelatinous  mu- 
coid matter — probably  secretion  from  the  inflamed  bronchial  mucous  mem- 
brane which  has  been  drawn  into  the  alveoli.  In  all  cases  of  catarrhal 
pneumonia  large  quantities  of  thick  purif orm  bronchial  secretion  are  found 
fiUing  the  air-ceUs  and  plugging  the  finest  tubes.  When  this  is  very  copi- 
ous the  amount  of  epithelial  cells  is  comparatively  insignificant.  Thus, 
some  of  the  nodules  of  consolidation  appear  to  be  composed  almost  exclu- 
sively of  thick  bronchial  secretion  ;  and  a  microscopic  examination  shows 
very  few  proliferated  cells  and  little  change  in  the  epithehal  lining  of  the 
alveoH.     In  other  parts  the  nodules  are  composed  almost  entirely  of  epi- 


436  DISEASE  IN   CHILDREN. 

thelial  elements,  and  the  epithelium  lining  the  alveolar  walls  is  swollen, 
granular,  and  partially  detached. 

These  lesions  are  found  in  both  lungs  ;  and  the  process  begins  in  the 
most  depending  part,  i.e.,  in  the  lower  lobes  at  the  posterior  aspect ;  for 
gravitation  greatly  aids  the  passage  into  the  cells  of  these  parts  of  purulent 
secretion  descending  from  the  tubes.  The  extension  of  the  inflammation 
laterally  is  always  irregular,  and  the  selection  of  the  lobules  for  attack  ap- 
parently capricious  ;  for  while  some  become  consolidated,  others  in  imme- 
diate contact  with  them  remain  healthy  or  merely  congested.  The  nodules 
and  patches  of  solidification  are  at  first  isolated,  but  tend  to  coalesce,  and 
in  the  latter  period  of  the  disease  comparatively  wide  areas  of  consolida- 
tion may  be  found. 

The  pleura  in  the  neighbourhood  of  the  spots  of  consolidation  is  red- 
dened with  points  of  ecchymosis,  and  adhering  to  it  is  often  a  little  plastic 
lymph. 

If  the  case  do  not  terminate  unfavourably,  resolution  usually  ensues.  A 
process  of  fatty  degeneration  takes  place  in  the  contents  of  the  alveoh. 
The  consolidating  material  becomes  softened  down  and  is  removed  more  or 
less  rapidly  by  absorjjtion  and  expectoration.  The  process  of  resolution 
often  occupies  some  time  even  when  the  lung  finally  returns  to  a  normal 
condition.  Often,  however,  the  process  of  fatty  metamorphosis  becomes 
arrested.  The  cells  then  atrophy  and  become  caseous,  and  a  chronic  con- 
solidation is  left  which  forms  one  of  the  varieties  of  jjulmonary  phthisis. 
In  other  cases  an  indurative  pneumonic  process  is  set  up  which  leads  to  a 
great  development  of  fibroid  tissue  in  the  part.  The  walls  of  the  air-tubes 
and  the  alveoU  become  thickened  and  indurated  and  the  tubes  dilated. 
This  condition  forms  a  special  variety  of  lung  disease  which  will  be  after- 
wards described  (see  fibroid  induration  of  the  lung). 

Symptoms. — Broncho-pneumonia  is  a  secondary  disease.  Its  symptoms 
are  always  preceded  by  those  characteristic  of  a  more  or  less  severe  pul- 
monary catarrh.  In  weakly,  ill-nourished  children,  especially  if  they  are 
suffering  fi-om  an  attack  of  measles,  a  comparatively  trifling  catarrh  will 
set  up  lobular  inflammation  of  the  lungs.  In  a  robust  child  inflammation 
of  the  alveoli  seldom  ensues  unless  the  preliminary  catarrh  has  been  long 
continued  or  very  severe.  When  broncho-pneumonia  follows  an  ordinary 
catarrh  of  the  lungs,  the  disease  usually  runs  a  very  acute  and  rapid  course 
and  commonly  ends  in  death.  "When  it  arises  in  the  course  of  an  attack  of 
measles  or  whooping-cough  the  complication  is  more  subacute  in  charac- 
ter and  the  proportion  of  recoveries  is  greater.  Still,  such  cases  tend  to 
leave  unabsorbed  deposits  in  the  lungs. 

After  the  symptoms  of  pulmonaiy  catarrh  have  continued  for  some  time 
they  suddenly  change  their  character.  The  temperature  rises  ;  the  cough 
becomes  short  and  hacking  ;  the  pulse  and  respirations  are  hurried  ;  the 
face  is  more  or  less  livid  ;  the  nares  act ;  and  in  the  infant  a  well  marked 
labial  line  becomes  developed,  passing  from  the  angle  of  the  mouth  down- 
wards and  outwards  to  the  ramus  of  the  lower  jaw. 

The  pyrexia  varies  in  degree.  In  children  in  whom  an  ordinary  bron- 
chitis gives  rise  to  fever,  the  temperature,  when  inflammation  of  the  lung 
is  superadded,  may  reach  a  high  level.  Thus,  the  thermometer  may  mark 
104°  or  105°,  but  undergoes  more  decided  variations  during  the  twenty- 
four  hours  than  is  the  case  in  croupous  pneumonia.  In  most  instances  there 
is  a  decided  remission  between  6  a.m.  and  noon  ;  the  chief  elevation  occur- 
ring between  10  p.m.  and  3  or  4  a.m.  Sometimes,  however,  for  twenty-four 
or  forty-eight  houi's  the  temperature  may  remain  at  about  the  same  level, 


CxVTAERHAL   PlSTEUMOTaA — SYMPTOMS.  437 

varying  only  by  half  a  degree.     In  spite  of  the  pyrexia  the  skin  is  often 
moist,  and  in  some  cases  perspiration  is  profuse. 

In  catarrhal  as  in  croupous  pneumonia  the  pulse-respiration  ratio  is 
perverted  ;  but  the  disproportionate  rapidity  of  the  breathing  is  variable 
according  to  the  acuteness  of  the  case  In  the  severe  acute  variety  the 
ratio  may  be  1  to  2  or  even  1  to  1.5  ;  while  in  the  subacute  form  the  ratio 
may  be  only  1  to  2.5  or  3.  The  pulse  is  very  rapid  (120  to  150,  or  even 
higher),  but  is  small  and  feeble,  for  the  impediment  to  the  passage  of  blood 
through  the  lungs  obstructs  the  whole  circulation.  Consequently  the  ar- 
teries are  comparatively  empty,  while  the  venous  system,  as  is  shown  by 
the  fulness  of  all  the  superficial  veins,  is  congested. 

The  breathing  besides  being  hurried  is  laborious,  and  there  is  evident 
dyspnoea.  The  child  often  cannot  lie  down  in  bed  and  has  to  be  supported 
by  pillows.  At  each  inspiration  the  nares  dilate  widely,  and  the  shoulders 
rise  with  the  laboured  action  of  the  accessory  muscles.  Often  the  child 
endeavours  to  aid  the  expansion  of  his  chest  by  grasping  tightly  the  bars 
of  his  cot.  Still,  with  all  his  endeavours  the  patient  is  unable  to  fill  his 
hmgs  with  air,  for  at  each  movement  of  the  chest  the  intercostal  spaces  and 
supra-clavicular  hollows  become  dejDressed,  the  epigastrium  sinks  in,  and 
the  lower  ribs  are  retracted. 

The  cough,  when  the  air-cells  become  attacked,  changes  its  character 
and  seems  painful.  This  change  in  the  cough  is  a  very  valuable  sign.  In- 
stead of  the  j)rolonged,  rather  paroxysmal  cough  of  bronchitis,  vv^e  hear 
the  short  hard  hack  of  pneumonia  ;  and  this  may  be  repeated  with  each 
expiration  for  many  minutes  together,  causing  great  distress  and  exhaus- 
tion. 

Looseness  of  the  bowels  is  a  common  symptom,  the  stools  being  slimy 
and  thick,  or  thin  and  watery.  Vomiting,  induced  by  the  cough,  is  also 
often  present  ;  and  much  mucus  is  discharged  both  from  the  stomach  and 
lungs.  Nervous  symptoms  are  sometimes  noticed.  In  an  uncomplicated 
case  convulsions  do  not  occur  in  the  course  of  the  iUness,  although  they 
may  be  present  shortly  before  death  when  asphyxia  is  imminent ;  but  twitch- 
ings  and  spasmodic  movements  of  the  muscles  of  the  eyeball  are  often 
seen  during  sleep. 

At  this  time  a  physical  examination  of  the  chest  discovers  merely  the 
signs  of  bronchitis  ;  for  the  consolidation  being  limited  to  small  scattered 
nodules  and  surrounded  by  emphysematous  air-cells,  can  rarely  be 
detected  by  percussion.  Sometimes,  however,  by  employing  broad 
percussion,  i.e.,  by  striking  with  three  fingers  on  three  fingers  applied 
to  the  chest-wall  as  pleximeters,  we  notice  some  diminution  of  healthy 
pulmonary  tone  ;  and  in  some  cases  a  careful  exploration  distinguishes 
certain  spots  where  there  is  more  evident  diminution  in  resonance,  and 
perhaps  bronchial  breathing  over  the  same  Hmited  area.  If  the  pneu- 
monia occurs  in  collapsed  portions  of  lung  we  can  often  find  at  each  base 
a  pyramidal  strip  of  dulness  reaching  upwards  for  a  certain  distance,  when 
percussion  is  made  very  lightly.  With  the  stethoscope  general  fine  bub- 
bling rhonchus  is  heard,  and  in  certain  spots  this  will  be  noticed  to  be 
finer,  dryer,  and  more  crepitating  in  character.  This  crepitating  quality 
is  especially  noticeable  over  an  area  where  the  breathing  is  bronchial ;  for 
unlike  croupous  pneumonia,  the  crepitus  is  not  lost  when  consohdation  oc- 
curs. 

As  the  illness  advances,  and  the  nodules  of  consolidation  grow  larger 
and  coalesce,  more  and  more  of  the  respiratory  sui-face  becomes  involved, 
so  that  cyanotic  symptoms  are   manifest.     The   face   grows   excessively 


438  DISEASE  m   CHILDEEN. 

pale,  TAdth  a  dusky  tint  around  the  eves  and  montli  ;  the  expression  is 
anxious  ;  the  eyeballs  are  staring-  and  suffused.  The  I'espii-ations  may 
rise  to  70,  80,  or  even  more  in  the  minute  ;  and  the  breathing  grows 
more  and  more  laborious.  The  child  is  painfully  ajoathetic  and  dull 
If  an  infant,  he  refuses  his  bottle,  and  can  with  difficulty  be  per- 
suaded to  swallow  fluids  from  a  spoon.  His  hands  and  feet  ai'e  pui-ple  and 
often  cold  to  the  touch,  although  the  internal  temjoerature  of  the  body  is 
still  febrile.  At  this  period  cough  almost  ceases,  partly  from  exhaustion, 
partly  from  impaii'ed  initabihty  of  the  respiratoiy  centre.  In  this  state 
the  child  sinks  and  dies,  the  end  being  often  preceded  by  a  fit  of  convul- 
sions. Before  death,  when  this  takes  jDlace  from  asphyxia,  the  internal 
temperature  may  be  subnormal.  In  the  case  of  a  httle  rickety  boy,  aged 
thirteen  months,  with  only  two  teeth,  who  died  on  the  eleventh  day  from 
extensive  catarrhal  pneumonia  of  both  lungs,  the  temperature  at  6  p.m. 
on  the  evening  before  death  had  fallen  to  98^  in  the  rectum. 

At  this  stage  of  the  disease  percussion  discovers  more  or  less  extensive 
dulness  of  the  back  on  each  side  ;  and  the  breathing  is  bronchial  or  tubu- 
lar, especially  about  the  angle  of  the  scapula.  The  respiration  is  accompa- 
nied by  much  fine  metaUic  crepitation  both  in  inspii-ation  and  expii'ation  ; 
and  this  is  often  very  supei-ficial-sounding,  as  if  generated  immediately 
underneath  the  stethoscope.  In  the  front  of  the  chest  there  is  seldom 
dulness,  unless  perhaps  the  resonance  at  the  bases  is  diminished  ;  but 
usually  a  certain  amount  of  coai-se  crepitation  may  be  heard  in  the  mam- 
mary and  infra-mammary  region  on  each  side.  A  curious  feature  at  this 
time  is  the  indifference  of  the  child  to  the  discomforts  of  the  examination. 
He  allows  himself  to  be  j^laced  in  any  jDOsition  without  complaint,  and 
seems  to  be  c|uite  careless  what  is  done  to  him. 

If  the  disease  terminate  favourably,  there  is  no  critical  fall  of  temper- 
ature, as  is  the  case  with  the  croupous  variety  of  pneumonia.  On  the  con- 
trary, the  diminution  in  the  pyrexia  takes  place  very  gi'adually,  and  the 
improvement  in  the  general  condition  does  not  occur  until  the  local  symp- 
toms have  given  signs  of  amendment.  Thus,  the  pulse  and  respii'ation 
are  reduced  in  frequency,  the  breathing  becomes  less  laborious,  the  pulse 
fuller,  and  the  superficial  veins  less  distended.  The  pallor  and  lividity 
of  the  face  are  less  noticeable  and  the  expression  loses  its  distress.  The 
tongue  cleans,  vomiting  ceases,  and  the  appetite  returns.  Still,  the  tem- 
peratui'e,  although  it  continues  to  fall,  is  some  days  before  it  sinks  to  a 
natural  level.  The  physical  signs  are  also  very  slow  to  improve,  and  ab- 
sorption takes  place  very  gradually.  This  variety  of  pneumonia,  as  has 
been  said,  is  apt  to  leave  behind  it  caseous  unabsorbed  masses  in  the  lung 
which  may  lead  to  serious  illness  in  the  future.  Still,  under  favoiu-able  con- 
ditions these  often  become  absorbed  even  although  a  period  of  months  has 
elapsed  since  the  attack  was  at  an  end. 

If  the  disease  do  not  prove  fatal  or  show  signs  of  resolution  at  the  end  of 
a  week  or  ten  days,  it  often  takes  on  a  subacute  course.  In  some  cases,  espe- 
cially where  the  catarrhal  pneumonia  occurs  as  a  comphcation  of  measles 
or  whooping-cough,  the  subacute  character  may  jorevail  fi'om  the  fii'st. 
In  this  form  the  symptoms  are  less  severe  than  in  the  acute  variety,  and 
the  course  of  the  disease  is  much  longer.  The  temperature  does  not  reach 
so  high  a  level,  remaining  usually  at  about  102  %  with  morning  remissions. 
Sometimes  the  pyrexia  undergoes  curious  alternations.  Thus,  after  being 
moderate  for  a  few  days  (99"-101'')  the  temperature  suddenly  shoots  up  to 
104""  or  105",  and  after  a  day  or  two  sinks  again  to  the  same  level  as  be- 
fore.    The  pulse  and  respii-ation  ai-e  both  hui-ried,  but  theii'  normal  rela- 


CATAERHAL   P]SrEUMO]N"IA — COMPLICATIONS — DIAGNOSIS.        439 

tion  is  comparatively  little  altered.  As  tlie  disease  advances  the  cougli 
loses  its  hacking  character  and  occurs  in  violent  paroxysms  almost  indis- 
tinguishable fi'om  those  of  pertussis.  Their  duration  is,  however,  shorter, 
and  inspu'ation  is  noiseless  or  less  decidedly  crowing.  They  may  be  fol- 
lowed by  vomiting.  This  character  of  the  cough  should  lead  us  to  sus- 
pect considerable  dilatation  of  the  bronchi. 

Vomiting  and  some  looseness  of  the  bowels  are  common  symptoms. 
The  tongue  is  furred  ;  the  appetite  is  impaired  ;  the  strength  is  diminished ; 
and  the  child  wastes  rapidly  and  becomes  very  feeble.  In  these  cases,  in 
addition  to  the  physical  signs  of  broncho-pneumonia  which  have  been 
already  described,  we  find  very  clear  evidence  of  dilatation  of  bronchi.  At 
each  posterior  base,  but  more  pronounced  on  one  side  than  on  the  other, 
cavernous  breathing  is  heard  with  a  coarse  metallic  ringing  crepitation, 
sounding  very  close  to  the  ear  ;  or  the  resj)iratory  sound  may  be  amphoric 
with  tinkling  echo.  In  many  cases,  too,  the  vocal  resonance  is  broncho- 
phonic,  and  the  faintest  laryngeal  sound  is  conducted  clearly  to  the  end  of 
the  stethoscope. 

These  cases  often  continue  for  weeks,  but  under  judicious  treatment 
generally  end  in  recovery.  There  is,  however,  a  gi'eat  tendency  to  imperfect 
absorption  of  the  deposit ;  and  unless  the  chUd  be  placed  under  favoura- 
ble sanitary  conditions  a  chronic  consolidation  may  be  left  which  is  after- 
wards a  soui'ce  of  danger.  Sometimes,  too,  these  cases  pass  into  fibroid 
induration  of  the  lung. 

Complications. — The  comphcations  of  simple  catarrhal  pneumonia  are 
not  numerous.  The  illness  sometimes  begins  with  stridulous  laryngitis, 
and  in  the  rare  cases  where  the  spasmodic  disease  ends  fatally  death  is 
usually  due  to  the  presence  of  the  pulmonary  inflammation.  Gastric  and 
intestinal  catarrh  have  already  been  mentioned  as  frequent  complications 
of  the  pneumonia.  In  the  child  a  catarrh  is  seldom  simple  ;  often  several 
tracts  of  mucous  membrane  share  in  the  derangement. 

Catarrhal  pneumonia  is  itself  also  a  common  complication  of  other 
forms  of  illness.  Measles,  whooping-cough,  and  rickets  have  ah-eady  been 
referred  to.  General  tuberculosis  in  many,  perhaps  in  most,  instances 
becomes  comphcated  with  this  form  of  pulmonary  inflammation  ;  and 
in  the  case  of  fibroid  indui^ation  of  the  lung  the  danger  of  the  disease 
consists  in  a  great  measure  in  the  repeated  attacks  of  catarrhal  pneu- 
monia to  which  children  with  this  form  of  lung  affection  are  peculiarly 
prone. 

Diagnosis. — At  the  beginning  of  the  illness  we  have  to  found  our  diag- 
nosis upon  the  general  symptoms  alone,  for  there  is  at  first  no  sign  of 
consolidation,  and  physical  examination  of  the  chest  only  reveals  the  pres- 
ence of  severe  bronchitis.  Mere  elevation  of  temperature  is  no  proof  that 
the  inflammation  has  spread  to  the  alveoli,  for  in  many  children — especi- 
ally those  with  scrofulous  tendencies — a  pulmonary  catarrh  is  accompanied 
by  moderate  pyrexia.  If,  however,  the  temperature  reach  104°  or  105,° 
and  at  the  same  time  the  cough  get  suddenly  short,  hacking,  and  painful, 
while  the  breathing  becomes  disproportionately  qmckened  so  as  to  cause 
notable  perversion  of  the  pulse-respiration  ratio,  this  combination  of 
symptoms  is  veiy  suggestive  of  catarrhal  j)neumonia.  A  peiwerted  pulse- 
respiration  ratio  alone  is  not  characteristic,  for  this  may  occur  in  cases  of 
collapse  of  the  lung.  Still,  if  with  great  hun-y  of  breathing  we  find  the 
respii'atory  movements  laborious,  and  notice  that  the  soft  parts  of  the  chest 
recede  deeply  at  each  breath,  the  sign  is  in  favour  of  pneumonia  ;  for  in 
pulmonary  collapse  the  breathing,  although  excessively  hiu'ried,  is  shallow. 


440  DISEASE  IN   CHILDEEIST. 

and  unless  the  ribs  are  mucli  softened  from  rickets  the  recession  at  the 
base  of  the  chest  is  shght. 

Quite  at  the  beginning  of  the  iUness  it  may  be  difficult  to  distinguish  the 
disease  from  the  croupous  form  of  pneumonia  where  the  signs  of  consohda- 
tion  are  delayed.  At  this  time  the  age  of  the  child,  the  history  of  the  attack, 
and  the  character  of  the  breathing  are  important  points  of  distinction. 
In  an  infant  the  inflammation  is  probably  catarrhal,  and  if  the  child  is  frail 
or  badly  nourished,  is  almost  certainly  so.  The  history  of  previous  cough 
points  strongly  to  the  lobular  form  ;  and  laborious  breathing,  great  reces- 
sion of  the  chest-walls  in  inspiration  and  a  very  evident  feeling  of  dyspnoea 
are  distinctive  of  catarrhal  rather  than  of  croupous  pneumonia.  The  latter 
disease  rarely  attacks  a  feeble,  ill-nourished  infant ;  it  comes  on  suddenly 
without  previous  catarrh ;  the  breathing,  although  hurried,  is  not  labo- 
rious ;  and  there  is  no  true  dysi^noea,  the  child  not  being  distressed  by  the 
recumbent  posture. 

When  extensive  areas  of  lung  have  become  consolidated,  the  catarrhal 
origin  of  the  lesion  is  distinguished  by  attention  to  the  crepitation.  This 
rale  in  croupous  pneumonia  ceases  to  be  heard  over  the  solidified  area  and 
can  only  be  detected  at  its  confines.  In  catarrhal  pneumonia  the  crepitat- 
ing rhonchus  becomes  finer  and  crisper  towards  the  centre  of  the  consoli- 
dation, and  is  heard  with  the  most  typical  bronchial  or  blowing  breathing, 
being  sometimes,  indeed,  so  copious  as  almost  or  entirely  to  cover  the 
breath-sound.  Moreover,  moist  and  dry  bronchitic  rales  are  heard  over  the 
lungs  generally.  In  croupous  pneumonia  this  is  not  often  the  case,  for  al- 
though some  sonoro-sibilant  rhonchus  is  occasionally  present,  this  is  trifling 
in  amount,  and,  as  a  rule,  is  not  accompanied  by  moist  sounds. 

One  of  the  chief  difficulties  in  the  case  of  catarrhal  pneumonia  is  to  ex- 
clude tuberculosis.  That  we  should  be  able  to  do  so  is  of  the  greatest  im- 
portance wdth  regard  to  prognosis ;  for  while,  if  the  inflammation  be  uncom- 
plicated, recovery  may  take  place,  if  the  child  is  tubercular  death  is  certain. 
The  subacute  form  of  the  disease  occurring  in  a  weakly  child  and  accomjDa- 
nied  by  diarrhoea  and  rapid  wasting,  presents  symptoms  which  are  identical 
with  those  resulting  from  acute  tuberculosis  with  secondary  lung  complica- 
tion. The  physical  signs  are  also  the  same,  for  no  additional  feature  is  fui*- 
nished  by  the  presence  of  the  gray  granulation  in  the  lungs.  Family  history 
is  here  of  importance.  If  we  can  discover  that  other  children  of  the  same 
parents  have  died  with  symptoms  of  tubercular  meningitis,  the  history  is 
suggestive  of  tubercle.  If,  again,  we  can  learn  that  before  the  onset  of  the 
disease  the  child  was  losing  strength  and  growing  pale  and  thin  without 
evident  cause,  the  fact  is  also  in  favour  of  tuberculosis.  Again,  the  age  of 
the  patient  must  be  considered.  Over  the  age  of  six  years  catarrhal  is  less 
common  than  croupous  pneumonia.  Therefore,  if  the  catarrhal  inflamma- 
tion occurs  in  a  child  more  than  six  years  old,  who  has  been  previously 
wasting  without  apparent  reason,  and  has  not  lately  suffered  from  measles 
or  whooping-cough,  we  have  here  strong  evidence  in  favour  of  tubercle.  Of 
the  actual  symptoms  the  only  one  which  in  any  way  points  to  a  constitu- 
tional cause  for  the  ilhaess  is  the  presence  of  oedema  without  albuminuria  ; 
but  this  phenomenon,  although  it  may  add  weight  toother  evidence,  is  in 
itself  of  little  value  in  a  weakly  child.  If,  however,  any  serious  symjDtoms 
arise  pointing  to  the  brain,  and  convulsions  occur,  followed  by  squint, 
unequal  pupils,  ptosis,  or  rigidity  of  joints,  we  can  have  no  hesitation  in 
concluding  the  case  to  be  one  of  acute  tuberculosis.  It  must  be  remem- 
bered that  terminal  convulsions  are  common  in  catarrhal  pneumonia  from 
asphyxia,  and  are  quickly  followed  by  death.     But  convulsions  occurring  in 


CATARRHAL   PNEUMONIA — PROGNOSIS — TREATMENT.         441 

the  course  of  the  illness  and  not  evidently  the  consequence  of  impurity  of 
blood,  are  very  suspicious  of  tuberculosis,  even  although  no  other  sign  of 
nerve-lesion  be  immediately  manifested. 

"When  dilatation  of  the  bronchi  occurs  in  an  advanced  case  of  the  sub- 
acute variety  of  catarrhal  pneumonia  it  is  important  to  exclude  ulcerative 
destruction  of  lung.  Thus,  in  the  fifth  or  sixth  week  of  a  broncho-pneu- 
monia a  child  is  seen  v^ith  a  temperature  of  100°  in  the  morning,  rising  to 
102°  or  103°  at  night.  At  the  same  time  an  examination  of  the  chest  dis- 
covers a  fine  crepitating  rhonchus  at  the  base  of  each  lung,  with  impaired 
resonance  over  the  lower  half  posteriorly  of  each  side,  and  at  one  basedul- 
ness,  loud  cavernous  breathing,  metaUic  gurgling  rhonchus,  and  broncho- 
phony. These  latter  signs  are  evidently  significative  of  a  cavity  ;  but  the 
cavity  may  be  a  dilated  bronchus  or  a  vomica  in  the  lung.  To  which  of 
these  causes  the  physical  signs  are  to  be  attributed  must  be  decided  by 
reference  to  the  general  symptoms  and  the  pi'ogress  of  the  case.  The  po- 
sition of  the  cavity,  indeed,  at  the  base  of  the  lung,  points  rather  to  bron- 
chiectasis than  to  a  vomica,  but  this  is  not  conclusive  proof.  If,  however, 
we  find  that  the  temperature  begins  to  fall,  the  child's  appetite  to  return, 
the  general  nutrition  to  improve,  and  at  the  same  time  notice  that  the 
cavernous  sounds  become  less  intense,  the  respiration  less  shrill,  and  the 
gurghng  less  metallic,  we  may  safely  infer  that  no  disintegration  of  lung- 
tissue  has  taken  place. 

Prognosis. — The  prospect  of  the  patient's  recovery  in  a  case  of  broncho- 
pneumonia is  always  doubtful.  In  new-born  infants,  indeed,  the  illness 
almost  invariably  terminates  fatally  ;  but  even  up  to  the  end  of  infancy  the 
rate  of  mortality  is  very  high.  When  the  disease  succeeds  to  measles  or 
whooping-cough  its  course  is  less  acute  than  when  it  arises  as  a  consequence 
of  simple  pulmonary  catarrh,  and  in  these  cases  there  is  a  greater  propor- 
tion of  recoveries.  If,  however,  the  lobular  pneumonia  come  on  during  the 
spasmodic  stage  of  pertussis,  or  towards  the  beginning  of  an  attack  of 
measles,  it  is  very  commonly  fatal.  The  existence  of  any  debilitating  con- 
dition or  exhausting  disease  increases  the  danger  of  the  case.  Thus  in 
diphtheria  the  occurrence  of  secondary  broncho-pneumonia  is  an  event  of 
the  utmost  gravity ;  and  in  rickets  the  local  weakness  of  the  softened  ribs, 
combined  with  the  general  want  of  power  in  the  patient,  militates  power- 
fully against  a  favourable  termination  to  his  illness.  The  danger  is  usually 
great  in  proportion  to  the  degree  to  which  aeration  of  the  blood  is  inter- 
fered with.  Therefore  lividity  of  the  face,  blueness  of  the  nails,  lips,  and 
eyelids,  smallness  and  rapidity  of  the  pulse  with  dilatation  of  the  suiDerficial 
veins,  great  perversion  of  the  pulse-respiration  ratio,  suppression  of  the 
cough,  and  marked  apathy  or  somnolence  are  symptoms  indicative  of  serious 
danger.  If  convulsions  occur  at  a  late  period  of  the  illness  we  must  jDrej^are 
the  child's  relatives  for  the  worst. 

Treatment. — The  occurrence  of  catarrhal  pneumonia  may  often  be  pre- 
vented by  judicious  treatment  of  the  preHminary  catarrh,  and  especially  by 
the  employment  of  energetic  measures  on  the  first  sign  of  collapse  of  the 
lung.     This  subject  is  discussed  elsewhere. 

When  lobular  pneumonia  has  supervened,  the  indications  to  be  fulfilled 
are  thi'ee  in  number.  We  have  to  reduce  the  temperature,  to  promote  ex- 
pansion of  the  lung,  and  to  support  the  strength  of  the  patient. 

In  order  to  lessen  the  temperature  tepid  bathing  is  often  resorted  to. 
The  child  should  be  placed  in  water  of  the  temperature  of  70°.  In  this  he 
may  remain  for  ten  or  fifteen  minutes  at  a  time.  The  bath  must  be  re- 
peated more  than  once  in  the  four-and-twenty  hours,  for  the  reduction  of 


442  DISEASE  iisr  childeeist. 

temperatui-e  is  only  a  passing  improvement,  and  the  p3-rexia  quickly  re- 
turns. This  method  is  highly  spoken  of  by  Eilliet  and  Barthez,  who"  rec- 
ommend its  employment  in  every  case,  unless  the  prostration  of  the  patient 
be  extreme.  Another  method  is  that  advocated  by  Bartels.  It  consists  in 
packing  the  child  in  a  cold,  wet  sheet,  covered  with  a  thick  folded  blanket, 
for  three  or  four  hours  at  a  time.  The  process  in  this  case  also  requires  to 
be  repeated  at  intervals,  so  long  as  no  signs  of  exhaustion  are  noted,  in 
order  to  maintain  the  improvement.  The  effect  of  either  of  these  measures 
is  not  only  to  lessen  the  fever,  but  also  to  increase  the  depth  and  reduce 
the  frequency  of  the  breathing. 

Another  very  valuable  resource  is  energetic  counter-irritation  of  the 
skin  of  the  chest.  A  large  poultice  of  mustard  and  Hnseed  meal  (one  part 
of  the  former  to  five  or  six  of  the  latter)  should  be  applied  for  six  or  eight 
hours  to  the  back.  Afterwards  a  similar  poultice  should  be  allowed  to  re- 
main for  a  like  time  on  the  front  of  the  chest.  On  removal  of  the  poultice 
the  chest  should  be  covered  with  cotton-wool.  These  applications  will 
often  have  to  be  repeated  several  times,  for  in  this  disease  there  is  great 
tolerance  of  irritation  of  the  skin  even  in  the  case  of  a  young  infant.  Even 
if  the  surface  is  bhstered  by  the  application,  no  harm  will  be  done. 
Indeed,  I  have  been  in  the  habit  of  ordering  the  poultices  to  be  continued 
until  some  sigTis  of  blistering  of  the  skin  have  been  noticed.  The  chest 
can  then  be  covered  with  cotton-wool.  In  bad  cases,  instead  of  the  mus- 
tard poultice,  dry  cupping  of  the  back  is  useful.  In  one  severe  case  of 
this  disease — a  child  of  three  years  of  age — I  attribute  the  recovery  of  the 
patient  entirely  to  the  timely  use  of  this  energetic  apphcation. 

While  these  methods  of  treatment  are  being  carried  out,  the  strength 
of  the  child  must  be  upheld.  Stimulants  should  be  given  early,  and  no 
attempt  to  lower  the  temperature  should  be  made  without  at  the  same  time 
administering  brandy  or  the  brandy-and-egg  mixture.  In  this  disease,  as 
in  all  others  which  rapidly  depress  the  powers  of  the  patient,  children 
respond  well  to  stimulants  ;  and  alcohol  should  be  given  every  two  or 
three  hours,  or  oftener,  according  to  the  strength  of  the  pulse,  the  rapidity 
of  the  breathing,  and  the  degree  of  pallor  and  lividity  of  the  face.  The 
effect  of  the  stimulant  is  to  give  strength  to  the  circulation,  to  reduce  the 
number  of  the  respirations  and  to  further  the  aeration  of  the  blood.  If 
the  child  cannot  or  will  not  swallow  the  remedy,  it  may  be  administered, 
as  in  other  exhausting  forms  of  illness,  by  the  syringe  and  elastic  tube  (see 
page  15),  or  through  a  caoutchouc  tube  passed  into  the  stomach  through 
the  nose. 

The  diet  must  consist  of  milk  diluted  with  barley-water  and  guarded 
by  a  few  drops  of  the  saccharated  solution  of  lime,  of  strong  beef-tea, 
yolks  of  eggs,  and  meat  essence.  In  the  case  of  young  infants  the  breast 
milk,  white  wine  whey,  and  milk  and  barley-water  with  Mellin's  Food  should 
be  given. 

With  regard  to  medicines  : — Emetics  are  useful  at  the  beginning  of  the 
disease.  A  drachm  of  ipecacuanha  wine,  or  half  a  grain  of  sulphate  of  cop- 
per dissolved  in  a  dessert-spoonful  of  water,  may  be  given  every  ten  minutes 
until  vomiting  is  produced.  This  remedy  must  not,  however,  be  repeated 
after  the  first  two  or  three  days,  as  the  strength  of  the  child  quickly  fails. 
Narcotics  are  to  be  avoided,  for  our  object  is  in  every  way  to  promote 
cough  in  order  to  maintain  efficient  expansion  of  the  air-cells  and  aid  the 
expulsion  of  secretion.  The  best  form  of  mixture  is  that  which  combines 
alkalies  with  stimulants.  Thus,  we  can  order  a  few  grains  of  bicarbonate  of 
soda  or  potash  with  four  or  five  di'ops  of  sal  volatile  and  an  equal  quantity 


CATAEEHAL  PNEUMONIA— TEEATMENT.  443 

of  spirits  of  chloroform  in  giycerine  and  water  every  three  hours.  Later, 
the  infusion  of  senega  or  serpentaria  may  be  substituted  for  the  water  in 
the  draught.  Medication  by  drugs  is,  however,  as  a  rule,  of  very  secondary 
importance  in  the  more  acute  forms  of  the  illness  ;  but  if  the  disease  occur 
as  a  complication  of  pertussis,  the  special  antispasmodic  treatment  for  that 
disease  may  have  to  be  continued. 

When  the  inflammation  runs  a  very  subacute  course  much  benefi.t  is 
often  derived  from  the  free  administration  of  iron.  For  a  child  five  or 
six  years  old  ten  drops  of  the  tincture  of  the  perchloride  of  iron  may  be 
given  every  three  hours,  freely  diluted  ;  and  a  rapid  improvement,  both 
in  the  physical  signs  and  general  symptoms,  often  follows  very  quickly. 
Directly  the  pyrexia  subsides  quinine  and  other  tonics,  and  cod-liver  oil 
should  be  given ;  and  the  child  should  be  removed,  as  soon  as  he  is  fit  for 
the  journey,  to  a  bracing  seaside  air. 


CHAPTER  YI. 

PLEURISY. 

Pleueist  is  a  very  common  disease  in  young  subjects,  and  one  which,  al- 
though seldom  immediately  fatal,  often  prodtices  remote  consequences  of 
a  very  serious  kind.  In  childhood  the  effused  fluid  becomes  pui-ulent  at  a 
very  early  period  ;  and  the  retention  in  the  chest-cavity  of  a  collection  of 
purulent  matter  seriously  hinders  the  nutrition  of  the  patient,  and  may 
lead  to  various  forms  of  disease,  both  general  and  local. 

Causation. — Pleurisy  is  comparatively  rare  during  the  first  twelve 
months  of  life.  It  becomes  much  more  common  during  the  second  year, 
and  after  that  age  is  one  of  the  most  frequently  met  with  of  all  diseases  of 
childhood.  The  inflammation  may  be  primary  or  secondary.  In  the  first 
case  it  appears  to  be  often  the  consequence  of  esposru-e  to  changes  of  tem- 
perature ;  at  least  it  is  difficult  to  discover  any  other  cause  for  it  than  a 
chill.  It  may  be  also  excited  by  mechanical  causes,  such  as  direct  ii'rita- 
tion  from  injury  to  the  chest-wall,  or  rupture  into  the  chest-cavity  of  ab- 
scesses or  hydatid  cysts.  Secondary  pleurisy  may  arise  from  extension 
of  inflammation  fi'om  the  lung,  the  pericardium,  or  the  peritoneum.  It  may 
occur  in  the  coui'se  of  acute  rheumatism,  scarlatina,  measles,  typhoid 
fever,  small-pox,  and  inherited  sj^phiHs  ;  and  is  very  often  a  consequence 
of  renal  disease,  and  sometimes  of  tuberculosis. 

3Iorhid  Anatomy. — Inflammation  of  the  pleui-a  is  usually  confined  to  one 
side  of  the  chest,  and  may  be  general  over  that  side  or  limited  to  cer- 
tain regions  (localised  or  loculated  pleurisy).  The  inflammation  begins  with, 
hyperjemia  of  vessels  and  infiltration  of  the  serous  and  subserous  tissues. 
An  efiusion  of  infiammatory  lymph  then  takes  place,  and  of  fluid  which  may 
accumulate  to  a  large  amount  in  the  pleru'al  ca\ity.  The  serous  membrane 
is  rough  and  lustreless,  and  becomes  coated  with  a  layer  of  effused  lymph. 
This  is  at  first  merely  a  thin,  coherent  membrane  ;  but  gradually  its 
thickness  increases.  The  surface  is  sometimes  ribbed  or  honeycombed  in 
appearance,  and  we  occasionally  see  strings  or  bands  of  lymph  passing  be- 
tween the  opposed  surfaces  of  the  pleura,  connecting  them  with  one  an- 
other. The  lymph  consists  of  albumen,  fibrine,  and  corpuscles  deiived 
from  proliferating  epithelium.  It  is  at  first  loosely  attached  to  the  serous 
membrane  beneath,  but  gTadually  becomes  more  firmly  adherent.  Event- 
ually new  vessels  form  in  it,  so  that  it  is  organised  and  converted  into  con- 
nective tissue.  In  this  way  the  opposed  surfaces  become  fii'mly  united, 
and  the  pleural  cavity,  where  these  adhesions  occtu',  is  obliterated. 

The  effused  fluid  is  at  first  yellowish  or  greenish,  and  transparent,  but 
it  soon  becomes  tui'bid  and  opaque,  and  in  chilch-en  very  quickly  puru- 
lent. The  serous  effusion  contains  both  albumen  and  fibrine,  and  coagu- 
lates spontaneously  after  removal.  The  pus  is  usually  quite  healthy  in 
appearance  and  without  unpleasant  smell  ;  but  in  exceptional  cases  it  is 
dark  coloiu'ed  and  very  offensive.     Sometimes  it  is  stained  or  streaked 


PLEURISY — MOEBID   ANATOMY — SYMPTOMS.  44o 

with  blood.  The  quantity  of  effused  fluid  is  veiy  variable.  It  may  be 
merely  an  ounce  or  two,  or  may  reach  two  or  three  pints.  When  thus 
copious,  the  whole  side  is  dilated,  the  intercostal  spaces  are  widened,  and 
neighbouring  organs  are  displaced.  The  lung  is  compressed,  and  if,  as 
sometimes  happens,  although  very  rarely  in  the  child,  it  is  bound  down  by 
a  thick  layer  of  false  membrane,  it  may  not  expand  again  as  the  fluid  be- 
comes absorbed.  In  that  case  it  leads  to  the  same  deformities  as  are  no- 
ticed under  similar  conditions  in  the  adult.  It  is,  however,  very  rare  to 
find  a  greatly  contracted  chest  from  an  old  pleurisy  in  the  child.  Even  if 
the  chest  fall  in  at  first,  it  will  be  often  found  to  right  itself  in  a  surprising 
way  in  the  coiu-se  of  time  ;  and  a  child  who  was  left  with  curved  spine  and 
retracted  ribs  may  be  seen  again,  after  an  interval  of  twelve  months,  with  a 
chest  as  symmetrical  as  if  it  had  never  been  affected.  It  is  rare  to  find  a 
child  permanently  deformed  by  this  means. 

In  some  cases  the  amount  of  fluid  is  small.  This  is  most  commonly  seen 
when  the  pleural  inflammation  is  secondary  to  peritonitis,  pericarditis,  or 
pneumonia.  Sometimes  the  pleural  cavity,  instead  of  forming  one  large  ab- 
scess, may  be  divided  into  several  distinct  sacs  by  false  membrane  and  ad- 
hesions, so  that  one  of  these  may  be  emptied  without  draining  the  others. 
It  is  not  so  very  uncommon  to  meet  with  more  than  one  loculated  empyema 
in  the  same  subject ;  and  great  difficulty  is  found  in  such  cases  in  com- 
pletely relieving  the  chest  of  its  purulent  contents. 

A  large  collection  of  purulent  fluid  in  the  pleural  cavity  rarely  becomes 
absorbed.  If  not  removed  by  operation,  a  spot  at  some  part  of  the  chest- 
wall — usually  the  fifth  interspace  in  the  inframammary  region — is  noticed 
to  be  red  and  very  tender.  This  soon  becomes  prominent  and  forms  a 
large  superficial  abscess,  which,  if  not  opened  artificially,  bursts  and  the  pus 
slowly  drains  away.  By  this  means  caries  of  a  rib  is  sometimes  produced. 
The  abscess  does  not  always  point  low  down.  It  may  appear  higher  up  in 
the  chest,  as  above  the  clavicle,  or  in  an  upper  intercostal  space  ;  and  I  have 
known  it  to  open  in  the  supraspinous  fossa.  In  some  cases,  instead  of 
bursting  externally,  the  purulent  collection  opens  into  a  bronchus  and  the 
matter  is  coughed  up  through  the  lung.  In  others  it  perforates  the  dia- 
phragm, and  passes  downwards  like  a  psoas  abscess  behind  the  peritoneum. 
Steiner  in  one  case  saw  it  open  into  the  gullet. 

Whether  the  fluid  be  removed  artificially  or  escape  by  perforation  of 
the  chest-wall,  it  may  after  a  time  drain  away  completely  and  leave  the 
patient  convalescent.  Sometimes,  however,  a  discharging  sinus  is  left  which 
remains  open  for  years.  In  these  cases  amyloid  disease  of  organs  often 
follows,  or  the  child  may  die  from  general  tuberculosis. 

Symptoms. — The  onset  of  pleurisy,  although  sudden,  is  not  often  violent. 
Usually  it  begins  with  a  feeling  of  chilliness,  or  in  older  children  with  a 
rigor,  and  with  pain  in  the  side,  followed  after  an  interval  by  cough.  It  is 
rarely  ushered  in  by  a  convulsive  seizure,  as  is  so  commonly  the  case  with 
pneumonia.  The  pain  is  often  severe.  It  is  felt  in  the  side  or  is  referred 
to  the  epigastrium  or  the  stomach.  In  infants  who  cannot  speak,  its  exist- 
ence is  announced  by  violent  fits  of  crying,  which  may  be  excited  at  once 
by  pressure  on  the  chest  as  in  lifting  the  child  up.  An  older  child  com- 
plains bitterly  of  the  pain,  and  often  gives  evidence  of  his  suffering  by  the 
distressed  expression  of  his  face,  especially  if  a  cough  cause  any  sudden 
movement  of  the  side.  There  is  also  tenderness  of  the  chest-wall  over  the 
seat  of  disease,  for  pressure  is  evidently  painful.  In  addition  to  the  above 
symptoms  there  is  generally  headache  ;  the  tongue  is  furred  ;  there  may  be 
vomiting,  and  for  the  first  few  days  there  is  always  fever,  even  in  cases 


446  DISEASE   IK   CHILDEElSr. 

where  the  temperature  is  afterwards  normal.  The  pulse  is  quickened,  and 
the  respirations  are  more  hurried  than  natural ;  but  they  are  not,  as  is 
the  case  with  jDneumonia,  increased  out  of  proportion  to  the  pulse.  Conse- 
quently, there  is  little  or  no  perversion  of  the  pulse-respiration  ratio.  The 
cough  does  not  usually  begin  -until  an  appreciable  interval  has  passed  froin 
the  onset  of  the  illness.  Often,  for  the  first  twenty-four  or  foi-ty-eight 
hours,  httle  cough  is  noticed.  When  it  comes  on  it  is  hard  and  dry,  and 
the  increased  movement  of  the  chest- walls  by  which  it  is  accompanied  is  a 
cause  of  much  suffering.  The  strength  of  the  child  fails  comparatively 
little.  There  is  by  no  means  the  marked  muscular  prostration  which  is  so 
noticeable  a  feature  in  pneumonia.  On  the  contrary,  if  the  pain  be  not 
severe,  the  child  seldom  takes  voluntarily  to  his  bed,  but  will  walk  about 
as  usual  without  any  pronounced  sense  of  fatigue.  If  the  pain  is  severe, 
he  is  quiet  and  indisposed  to  exert  himself  ;  but  this  inclination  to  rest  is 
the  consequence  of  pain,  which  is  increased  by  movement,  and  is  not  due 
to  any  sense  of  muscular  weakness. 

The  degree  of  fever  varies.  Usually  for  the  fii'st  few  days  the  tem- 
perature rises  to  102°  or  103°  in  the  evening,  falling  to  99°  or  100°  in  the 
morning.  After  the  first  week  the  fever  may  either  jDersist,  or  the  temper- 
ature may  fall  gradually  to  the  normal  level.  In  a  child  of  perfectly 
healthy  constitution,  if  the  pleurisy  be  primary  and  uncomplicated,  the 
fever  usually  is  moderate  and  quickly  subsides.  Persistent  high  tempera- 
ture in  a  case  in  which  the  pleurisy  is  primary  and  uncomplicated  is  usually 
a  sign  that  the  patient  is  of  strumous  constitution. 

It  is  not  in  every  case  that  the  onset  of  the  disease  is  so  marked  as  de- 
scribed above.  The  illness  often  begins  insidiously  and  is  only  discovered 
by  the  pallor  of  the  child,  and  the  shortness  of  his  breath  on  any  exertion. 
The  latent  form  of  the  disease  is  especially  common  in  infants,  particularly 
if  the  child  is  suffering  at  the  time  of  the  attack  from  any  wasting  disease. 
In  these  cases  there  is  often  no  fever,  or  only  a  trifling  rise  of  temperature  ; 
there  may  be  no  cough  ;  and  attention  may  only  be  du-ected  to  the  chest 
by  noticing  that  the  child  is  breathing  quickly  and  has  less  appetite  than 
usual  for  his  food. 

The  pain  of  pleurisy  is  usually  only  severe  at  the  beginning  of  the  ill- 
ness, and  often  subsides  as  effusion  takes  j)lace  into  the  pleura.  This  is 
not,  however,  always  the  case.  Sometimes  it  continiies  with  extreme  ten- 
derness of  the  affected  side  until  towards  the  close  of  the  disease.  Unless 
the  tenderness  be  great,  the  child  usually  hes  on  the  affected  side  for  the 
sake  of  gi^Tnig  increased  freedom  to  the  healthy  lung,  which  has  to  do 
double  duty  as  a  respiratory  organ.  If  the  tenderness  is  marked,  the  pa- 
tient lies  on  his  back.  It  is  not  often  that  he  is  seen  resting  on  the  sound 
side. 

If  the  disease  continues  for  two  or  three  weeks,  the  fluid  usually  becomes 
purulent.  There  are,  unfortunately,  no  positive  symptoms  which  indicate 
that  the  effusion  is  no  longer  serous.  Even  the  time  which  has  elapsed 
from  the  beginning  of  the  illness  is  no  positive  guide,  for  in  some  children 
the  fluid  becomes  purulent  much  more  quickly  than  it  does  in  others  ;  and 
in  exceptional  cases  it  may  be  purulent  from  the  first.  The  tint  of  the 
face  is,  however,  often  a  suspicious  symptom.  For  many  years  I  have  been 
accustomed  to  note  the  colour  of  the  face  in  children  the  subjects  of  jDleu- 
risy.  In  many  it  assumes  a  peculiar  straw-yellow  hue  which  is  unlike  the 
complexion  of  any  other  disease.  This  symptom  is  rarely  seen  during 
the  first  week  of  the  illness,  and  seldom  attracts  the  eje  before  the  end  of 
the  second  week.     If  well  defined,  it  is  often  coexistent  with  purulent 


PLEURISY — SYMPTOMS.  447 

change  in  tlie  contents  of  tlie  pleural  cavity.  Still,  I  have  seen  it  well  marked 
in  a  case  where  the  fluid  withdi-awn  by  the  aspirator  was  perfectly  clear.  A 
boy  in  the  East  London  Children's  Hospital,  aged  six  years,  was  noticed  to 
have  a  most  marked  straw-yellow  tint  of  the  face  and  neck.  The  left  side 
of  the  chest  was  full  of  fluid,  which  had  pushed  his  heart  into  the  epigas- 
trium. With  the  aspirator,  nineteen  ounces  of  clear  pale  yellow  fluid  were 
withdrawn. 

When  the  fluid  has  become  purulent  (empyema)  the  child  usually  wastes  -, 
but  great  differences  are  observed  in  the  extent  to  which  nutrition  suffers 
even  in  these  cases.  Much,  probably,  depends  upon  the  temperature,  as 
this  may  be  taken  to  indicate  with  fair  accuracy  the  degree  to  which  the 
system  is  fretted  by  the  purulent  contents  of  the  thorax.  If  there  be  much 
fever,  wasting  is  rapid.  The  child  has  a  distressed  expression  and  becomes 
profoundly  anaemic  ;  his  strength  diminishes  ;  the  straw  tint  of  the  face 
may  spread  more  or  less  over  the  whole  body  ;  the  skin  becomes  dry  and 
harsh,  and  the  fingers  get  clubbed  at  the  extremities.  In  very  rare  cases 
a  trace  of  oedema  may  be  detected  in  the  legs  without  albuminuria  ;  but  I 
have  knowTi  this  symptom  to  occur  only  in  one  instance,  and  in  this  albumi- 
nuria followed  after  a  few  weeks.  Empyema  in  scrofulous  subjects  is  al- 
most invariably  accompanied  by  fever.  The  temperature  rises  to  102^  or 
103°  at  night,  sinking  in  the  morning  to  the  natural  level.  In  children  of 
healthy  constitution  the  presence  or  absence  of  fever  appears  to  dejDend  in 
a  great  measure  upon  the  natural  nervous  excitabihty  of  the  child  and  his 
tendency  to  respond  readily  to  any  source  of  irritation.  In  many  children 
with  a  chest  more  than  half  full  of  purulent  fluid  the  temperature  is  nor- 
mal and  the  nutrition  fairly  good  ;  and  although  signs  of  anaemia  may  be 
noticed,  the  strength  and  spirits  are  not  greatly  depressed. 

The  2ihysical  signs  in  cases  of  pleurisy  in  the  child  must  be  studied  with 
attention,  for  they  often  resemble  those  of  croupous  pneumonia  very  closely. 
On  account  of  the  weakness  of  vocal  fremitus  in  early  life  no  assistance  is 
to  be  obtained  from  the  presence  or  absence  of  vibration  of  the  chest-wall 
— a  sign  which  in  the  adult  is  of  extreme  value  in  the  detection  of  fluid. 
The  auscultatory  signs,  also,  may  present  so  close  a  similarity  to  those  of 
inflammation  of  the  lung  that,  in  themselves,  without  reference  to  the  situa- 
tion in  which  they  occiir,  they  are  not  distinctive  of  pleurisy.  Indeed,  in 
many  cases  it  is  only  by  a  comparison  of  the  physical  signs  with  the  general 
symptoms  of  the  disease  that  we  can  arrive  at  an  accurate  conclusion  as  to 
the  nature  of  the  illness. 

On  inspection  of  the  chest-wall  we  can  often  detect  a  certain  impairment 
of  movement  on  the  affected  side  ;  but  the  intercostal  spaces  are  not 
necessarily  bulged  and  motionless  even  in  cases  where  the  amount  of  fluid 
is  large.  In  young  children,  whose  respiration  is  principally  diaphragmatic, 
the  walls  of  the  chest  move  comparatively  little  in  inspiration  ;  and  the 
closest  inspection  can  often  discover  no  difference  in  this  resj)ect  between 
the  two  sides.  Although  the  intercostal  spaces  may  move  as  in  health,  the 
whole  of  the  affected  side  is  fuller  than  the  other.  It  may  not,  indeed,  as 
has  been  pointed  out  by  Dr.  Gee,  show  any  difference  to  the  measuring 
tape  ;  but  the  outline,  as  taken  with  the  cyrtometer,  is  much,  squarer  than 
natural  from  a  bulging  at  the  antero-lateral  angle  of  the  chest-wall.  If  the 
amount  of  effusion  is  more  than  moderate,  the  neighbouring  organs  are 
displaced  by  pressure  of  the  fluid.  The  liver  and  spleen  can  be  felt  more 
distinctly  than  in  the  normal  state,  and  the  heart's  apex  is  pushed  to  one 
side.  In  cases  of  right-sided  pleurisy  the  apex  is  displaced  to  the  left,  and 
can  be  felt  beating  outside  the  nipple  line.     If  the  effusion  occupy  the  left 


448  DISEASE  IN   CHILDKEN. 

side,  the  cardiac  impulse  may  be  felt  near  the  ensiform  cartilage.  These 
signs,  especially  the  latter,  according  to  my  experience,  are  as  well  marked 
in  the  child  as  in  the  adult,  and  should  be  always  looked  for.  Displace- 
ment of  the  heart  to  the  right  is  sometimes  prevented  by  adhesions  formed 
between  the  pericardium  and  the  left  pleura.  Sometimes  an  alteration  in 
the  size  of  the  heart  may  prevent  the  displacement  of  the  organ  from  being 
noticed.  Thus,  if  the  left  ventricle  is  much  hypertrophied,  the  apex-beat 
under  ordinary  circumstances  is  felt  to  the  left  of  the  nipple  line.  In  such  a 
case  displacement  of  the  heart  to  the  right  by  fluid  in  the  left  pleura  may 
do  no  more  than  restore  the  apex-beat  to  the  normal  position.  A  little 
girl,  aged  nine  years,  with  old-standing  heart  disease  and  hypertrophy  of 
the  left  ventricle,  was  admitted  into  the  hospital  with  considerable  pleuritic 
effusion  of  the  left  side.  The  heart's  apex  was  felt  beating  behind  the 
sixth  rib  in  the  left  nipple  line.  After  absorption  of  the  fluid  the  cardiac 
apex  had  moved  one  inch  to  the  outer  side  of  the  nipj)le  line. 

Palpation  of  the  affected  side  does  not  always  discover  obliteration  of 
the  intercostal  depressions,  although  sometimes  it  wUl  do  so.  Often,  es- 
pecially in  cases  where  there  is  little  thickness  of  lymph  Uning  the  pleura, 
a  tap  with  the  finger  between  two  of  the  ribs  will  be  readily  transmitted 
through  the  fluid  to  a  second  finger  resting  upon  a  distant  part  of  the 
same  interspace.  Vocal  vibration  of  the  chest- wall  is,  as  a  rule,  completely 
absent  in  the  healthy  child.  Sometimes,  however,  if  strong  on  the  sound 
side,  it  may  be  conducted  by  the  chest-wall  to  the  other  haK  of  the  chest, 
and  be  felt  distinctly  over  the  whole  of  the  affected  side.  I  have  known 
this  phenomenon  to  be  present  in  a  case  where  ten  ounces  of  fluid  were 
removed  by  paracentesis.  Immediately  before  the  operation  the  vocal 
vibration  was  little  less  strong  than  on  the  sound  side.  On  account  of 
its  frequent  absence,  and  uncertain  value  when  present,  vocal  fremitus  is 
not  to  be  depended  upon  in  the  young  subject.  If,  however,  we  can  feel  a 
distinct  fremitus  over  the  sound  lung,  its  absence  over  the  affected  side  of 
the  chest  is  important ;  but  this  is  exceptional. 

On  percussion  of  the  affected  side  there  is  complete  dulness  with  greatly 
increased  sense  of  resistance.  These  are  very  important  signs.  In  no  form  of 
pulmonary  consolidation — except,  perhaps,  in  extensive  fibroid  indtu'ation 
of  the  lung  with  secondary  pneumonia — is  such  a  dull,  flat  note,  with  so 
marked  a  sense  of  resistance  to  the  finger,  to  be  found.  The  impression  to 
the  ear  and  the  touch  is  exactly  that  derived  from  percussing  a  thick  block 
of  wood.  The  dead,  flat  note  is  not,  however,  to  be  obtained  all  over  the 
affected  side  of  the  chest.  In  the  upper  intercostal  spaces  in  front,  and 
along  the  side  of  the  spine  behind,  a  tubular  (tympanitic)  note  is  often 
ehcited,  due  to  the  j^i'esence  of  under-lying  relaxed  lung-tissue  ;  and  in  the 
infra-axillary  region  it  is  common  to  find  a  well-marked  resonance,  owing  to 
the  transmission  of  the  stomach  note  through  the  lower  part  of  the  fluid. 
This  pseii(io-resonance  is  often  a  source  of  perplexity  ;  but  we  usually  find 
that  on  employing  very  gentle  percussion  in  this  region  the  note  is  dull, 
while  a  sharper  stroke  in  the  same  spot  produces  a  loud  resonance  such  as 
was  heard  at  first.  It  is  very  important  not  to  be  misled  by  this  source  of 
confusion,  for  one  of  the  distinctive  marks  of  fluid  in  the  pleura  Ues  in  the 
general  distribution  of  the  dull  percussion  note  on  the  affected  side.  In 
ordinary  cases  of  pleurisy  the  dulness  extends  all  round  the  side  of  the 
chest,  both  behind  and  in  front,  although  the  upper  limit  of  the  clidness 
rises  to  a  higher  level  at  the  back  than  it  does  anteriorly. 

Besides  the  general  distribution  of  the  dulness,  the  alteration  of  the 
percussion  note  on  change  of  position  is  a  valuable  sign  of  fluid  in  the  chest. 


PLEUEISY — SYMPTOMS.  449 

If  the  amount  of  fluid  is  moderate,  and  is  not  confined  within  narrow  limits 
by  adhesions,  it  tends  to  gravitate  to  the  most  depending  part,  so  that  the 
side  of  the  chest  which  is  turned  uppermost  gives  a  clear  note  to  the  per- 
cussing finger.  This  sign  is  almost  invariably  present  during  the  stage  of 
absorption.  ' 

The  auscultatory  signs  of  pleurisy  in  the  child  are  often  very  peculiar. 
Sometimes,  as  in  the  adult,  we  find  weak,  almost  suppressed,  breathing  over 
the  area  of  dulness,  with  an  occasional  graze  or  scrape  of  friction  above  the 
upper  border  of  the  effusion.  Often,  however,  the  signs  are  much  less 
characteristic.  It  is  not  uncommon  to  find  a  loud  blowing,  tubular,  or  even 
cavernous  breath-sound  over  the  scapula  behind  and  in  the  axillary  region. 
Sometimes  this  is  heard  almost  as  far  as  the  base,  and  usually  it  can  be  de- 
tected below  the  level  of  the  effused  fluid.  This  character  of  the  respira- 
tory sound  is  not  confined  to  cases  where  the  lung  is  consolidated  from 
pneumonia,  for  it  is  often  present  when  the  temperature  is  normal.  The 
vocal  resonance  may  be  exaggerated,  and  about  the  lower  angle  of  the 
scapula  is  frequently  bronchophonic.  Often  it  has  a  pronounced  £ego- 
phonic  quality.  The  bronchophonic  character  is  not,  however,  always 
found  in  places  where  the  breathing  is  bronchial  or  blowing.  Over  a  spot 
where  the  respiration  is  typically  tubular,  vocal  resonance  may  be  com- 
pletely suppressed. 

The  characters  of  the  friction-sound  in  children  are  also  j^eculiar.  It 
is  exceptional  to  hear  the  common  rub  or  scrajDe  which  is  so  familiar  a 
sign  in  the  adult  patient.  In  the  child  the  friction-sound  has  often  a 
crackling  or  crepitating  character,  which  to  the  inexperienced  ear  is 
suggestive  rather  of  intra-  than  of  extra-pulmonary  mechanism.  It  has 
not,  however,  the  puffy  character  of  jDneumonic  crepitation  ;  and  is  very 
superficial  sounding,  as  .if  generated  close  to  the  ear.  Often,  from  the 
character  of  the  sound  alone,  it  is  difiicult  to  say  whether  it  is  produced  in 
the  liuig  Or  in  the  pleura,  especially  as  a  large,  hard,  bubbling  rhonchus  is 
sometimes  heard,  which  is  evidently  of  intra-pulmonary  mechanism  and  is 
due  to  catarrh  of  the  air-tubes.     This  disappears  after  a  cough. 

The  friction  is  not  limited  to  spots  in  the  pleura  above  the  level  of  the 
fluid.  In  pleiu'isy,  as  in  pericarditis,  effusion  does  not  necessarily  suppress 
friction.  It  is  not  uncommon  to  hear  an  unmistakable  friction-sound  at  a 
spot  where  immediately  afterwards  the  aspirating  needle  withdraws  several 
ounces  of  fluid. 

In  cases  where  the  effusion  is  very  copious  the  symptoms  may  be  dis- 
tressing, and  the  child's  life  be  placed  in  the  greatest  danger.  This  is  espe- 
cially the  case  when  the  fluid  occupies  the  left  side  of  the  chest.  Li  this 
situation  it  may  push  the  heart  so  far  to  the  right  that  the  apex  is  felt, 
beating  under  the  right  nipple.  Consequently,  the  large  vessels  may  be 
bent  out  of  their  natural  course,  and  great  obstruction  to  the  circulation 
may  result  from  the  interference  with  their  calibre.  The  healthy  lung, 
hampered  in  its  functions,  may  become  engorged,  and  the  difiiculty  in 
the  return  of  blood  to  the  heart  may  j^roduce  great  congestion  of  the 
head,  face,  and  extremities.  The  child  is  seen  sitting  tip,  gasping  for 
breath,  with  an  agonized  expression  on  his  dusky  face.  His  eyes  are  star- 
ing and  congested  ;  his  hands  and  feet  are  purple  ;  his  skin  is  cold  and 
bathed  in  sweat  ;  the  veins  of  the  neck  are  swollen  ;  his  pulse  is  small, 
feeble,  and  frequent ;  and  unless  the  distress  be  qixickly  relieved  death  is. 
certain. 

Terminations. — In  cases  where  the  fluid  remains  serous,  it  usually  be- 
comes I'apidly  absorbed.  The  general  symptoms  are  slight  and  quickly 
'29 


450  DISEASE   IJSr   CHILDEEISr. 

subside,  and  the  physical  signs  retvirn  to  a  state  of  healtli.  In  these 
cases  dulness  on  percussion  and  weak  breathing  can  be  detected  longer  in 
the  infra-axillary  region  than  elsewhere.  If  absorption  of  the  fluid  be 
slow,  some  retraction  of  the  side  is  often  observed  for  a  time  ;  but  in  such 
cases  it  is  usually  shght,  and  is  seldom  noticed  to  the  degree  which  is  so 
common  after  removal  of  a  purulent  fluid  fi-om  the  chest.  If  absoi-ption 
is  complete,  the  deformity  soon  passes  away  and  the  chest  recovers  its 
symmetry. 

"When  the  fluid  has  become  pui'ulent,  absorption  goes  on  very  slowly. 
It  is  only  when  the  quantity  is  very  small  that  anything  approaching  to 
completeness  of  absorption  is  found.  It  is  in  cases  of  empyema  that 
clistortion  of  the  chest  is  commonly  noticed.  The  spine  becomes  curved 
with  the  concavity  towards  the  diseased  side  ;  the  shoulder,  nipple,  and 
inferior  angle  of  the  scapula  sink,  and  the  lower  part  of  the  shoulder- 
blade  jDrojects  backwards  from  the  chest-wall.  Such  retraction  of  the  af- 
fected side  takes  place  before  absorption  has  ceased.  Indeed,  as  Dr.  T. 
Barlow  has  very  justly  pointed  out,  the  fact  that  retraction  of  the  side  has 
occurred  is  by  no  means  a  positive  proof  that  absorj)tion  has  been  com- 
pleted. On  the  contrary,  if  the  deformity  continues  without  improvement, 
it  rather  tends  to  suggest  the  possibility  of  some  unabsorbed  purulent 
matter  remaining  at  the  base  of  the  lung  or  between  the  lobes.  In  many 
of  these  cases  a  layer  of  cheesy  matter  is  left  coating  the  base  of  the  lung  ; 
and  a  quantity  of  thick  creamy  pus  is  often  found  on  dissection  collected 
in  a  limited  abscess  on  the  surface  of  the  diajihragm. 

If  the  amount  of  purulent  fluid  is  large,  it  sooner  or  later,  unless  with- 
drawn by  the  asjoirator,  points  at  some  part  of  the  chest-wall.  If  this  oc- 
cur in  an  upper  intercostal  space,  the  contained  fluid  cannot  be  completely 
evacuated,  and  a  continuous  discharge  occurs  through  the  opening.  The 
child  grows  daily  weaker  and  thinner.  His  breath  is  short  ;  his  face  gets 
sallow  and  often  earthy  in  tint,  with  lividity  about  the  eyes  and  mouth  ; 
his  fingers  become  clubbed  ;  his  digestion  is  impaired,  his  tongue  foul, 
and  his  breath  offensive  ;  the  liver  and  spleen  become  enlarged  from  al- 
buminoid degeneration  ;  the  cough  is  spasmodic  and  painful ;  and  the 
child  sinks  and  dies  from  asthenia.  Death  may  be  preceded  by  profuse 
diaiThoea,  which,  sometimes  at  least,  is  due  to  albuminoid  change  in  the 
coats  of  the  bowel. 

If  the  abscess  point  in  a  lower  intercostal  space,  so  that  the  chest 
cavity  can  be  completely  drained,  recovery  may  occur  without  operative 
interference.  I  have  met  with  at  least  one  such  case  where,  although 
there  was  at  first  some  deformity  of  the  affected  side,  this  entirely  disap- 
peared ;  but  it  must  be  confessed  that  such  a  fortunate  result  is  not  com- 
mon. 

Sometimes  the  purulent  fluid,  instead  of  discharging  itself  through  the 
chest-wall,  perforates  a  bronchus  and  is  coughed  up  through  the  lung. 
Large  quantities  of  purulent  matter  may  be  thus  expectorated,  but  con- 
trary to  what  might  be  supposed,  no  aii'  enters  the  pleural  canity  and  the 
physical  signs  are  not  found  to  have  undergone  any  special  alteration. 
Indeed,  if  the  case  terminate  fatally,  it  is  very  rare  to  find  on  the  closest 
examination  any  du'ect  communication  between  the  lung  and  the  chest 
cavity.  Spontaneous  evacuation  through  the  lung  is  not  confined  to  cases 
where  no  oi^erative  procedure  has  been  attempted.  It  may  also  occur 
after  a  part  of  the  contained  fluid  has  been  removed  by  paracentesis.  This 
mode  of  ending  is  often  followed  by  complete  recovery.  If  the  pleural 
cavity  can  be  thoroughly  evacuated  by  this  means,  and  the  lung  is  not 


PLEUEISY — TERMINATIONS — VAEIETIES.  451 

bound  down  beyond  possibility  of  expansion,  recovery  may  take  place  with- 
out any  permanent  retraction  of  the  affected  side. 

A  little  boy,  aged  five  years,  was  brought  into  the  East  London  Chil- 
dren's Hospital  for  an  emjjyema  of  six  weeks'  standing.  The  effusion  occu- 
pied the  right  side  and  appeared  to  be  coj)ious,  for  the  intercostal  spaces 
were  obliterated  and  the  heart's  apex  was  felt  beating  to  the  outer  side  of 
the  left  nipple  line.  On  percussion,  dulness  was  complete  over  the  whole 
of  the  right  side,  both  back  and  front ;  there  was  marked  sense  of  resist- 
ance ;  and  the  breath-sounds,  although  blowing  in  quality,  were  excessively 
weak.     The  temperature  was  nonnal. 

A  few  days  after  the  boy's  admission  eleven  ounces  of  thick,  greenish, 
inodorous  pus  were  withdrawn  by  the  aspirator.  After  the  operation  the 
dulness  and  weak  blowing  breathing  remained  the  same,  but  the  intercostal 
spaces  had  become  visible,  and  the  heart's  apex  had  returned  as  far  as  the 
nipple  line.  A  week  afterwards  the  boy  coughed  up  twelve  ounces  of  thick 
pus,  and  in  a  few  days  a  further  four  ounces.  After  this  the  percussion 
note  was  decidedly  less  dull ;  the  resistance  was  diminished ;  and  the  breath- 
ing was  loud  and  tubular  over  the  whole  of  the  upper  half  of  that  side, 
cavernous  below.     Vocal  resonance  was  loud  and  segophonic. 

For  some  weeks  the  boy  continued  to  spit  up  several  ounces  of  puru- 
lent matter  every  few  days  ;  and  in  the  end  made  a  j)erfect  recovery  with- 
out any  contraction  of  the  chest-wall.  The  temperature  was  normal  as  a 
rule  ;  although  sometimes  it  would  suddenly  rise  to  103°  or  104°,  but  never 
remained  elevated  more  than  a  few  hours.  These  elevations  did  not  cor- 
respond with  or  precede  the  passage  of  pus  through  the  lung.  A  year 
afterwards  the  boy  was  readmitted  with  acute  pleurisy  of  the  opposite  side 
(the  left)  ;  and  this  attack  also  was  perfectly  recovered  from. 

In  many  cases  of  perforation  of  a  bronchus  there  is  the  same  difficulty 
in  completely  evacuating  the  pleural  cavity  as  is  found  when  the  discharge 
takes  place  through  the  chest-wall.  Sometimes  the  opening  into  the  bron- 
chus closes,  and  pus  ceases  to  be  expectorated.  Ketention  of  purulent 
matter  then  occurs,  and  the  chest  may  become  much  distorted,  or  the 
child,  after  a  lingering  illness,  may  die  of  asthenia. 

Even  when  the  operation  of  paracentesis  is  performed  and  the  puru- 
lent fluid  is  removed  artificially,  the  case  is  by  no  means  necessarily  at  an  end. 
Sometimes,  after  withdrawal  of  as  much  fluid  as  can  be  made  to  pass  through 
the  aspirator,  no  further  accumulation  occurs  ;  absorption  of  what  remains 
in  the  pleural  cavity  goes  on  uninterruptedly,  and  the  child  is  soon  well. 
These  cases  are,  however,  exceptional.  It  is  often  necessary  to  repeat  the 
operation  several  times,  and  not  unfrequently,  as  the  purulent  fluid  con- 
tinually reaccumulates,  other  measures  have  to  be  adopted  as  will  be  after- 
wards described.  In  prolonged  cases,  whether  a  fistula  be  present  in  the 
chest-wall  or  not,  secondary  tuberculosis  is  liable  to  occur  ;  and  it  is  not 
very  uncommon  to  find  great  enlargement  of  the  liver  and  spleen  from 
amyloid  degeneration. 

Another  occasional  consequence  of  long-standing  pleurisy  is  a  fibroid 
change  at  the  base  of  the  lung  leading  to  indiu-ation  of  the  tissues  and  di- 
latation of  bronchi.  This  subject  is  elsewhere  referred  to  (see  Fibroid  In- 
duration). 

Varieties.— Certain  varieties  of  the  disease  are  commonly  met  with.  In 
some  cases  the  lymph  exudation  is  unaccompanied  by  liquid  effusion  (plas- 
tic or  dry  pleurisy).  In  others,  the  inflammation,  instead  of  being  general 
over  the  whole  side,  is  confined  within  certain  limits  (localised  or  loculated 
pleurisy).     In  others,  again,  the  disease  may  attack  the  two  sides  simulta- 


452  DISEASE   IX   CHILDEEIS". 

neously.  Double  pleui'isy  is  often  in  the  chUd  the  consequence  of  tuber- 
culosis. 

Plastic  Pleurisy,  although  sometimes  primary,  is  for  the  most  part  in 
young  subjects  secondary  to  some  other  disease.  It  is  common  in  cases  of 
phthisis,  and  sometimes  occui'S  in  the  course  of  catarrhal  pneumonia.  Dry 
or  plastic  jDleurisy  is  often  overlooked,  as  it  may  give  rise  to  but  few  symp- 
toms, or  to  symptoms  so  slight  that  they  are  masked  by  the  other  more 
prominent  manifestations  of  the  disease  in  the  course  of  which  they  have 
arisen.  This  form  is  of  little  importance.  It  is  usually  accompanied  by 
some  pain  in  the  side  and  a  teasing  cough.  On  examination  of  the  chest, 
duluess  is  discovered  at  the  seat  of  pain,  and  a  little  crepitating  friction  or 
a  superficial  rub  can  be  heard  with  the  stethoscope.  The  inflammation 
leads  to  adhesion  between  the  opposed  surfaces  of  the  pleura'. 

Loculated  Pleurisy  is  vei-y  common  in  children.  The  inflammation  may 
occupy  any  part  of  the  serous  surface.  It  may  be  hmited  to  the  membrane 
covering  the  diaphragm  or  to  that  surrounding  the  base  of  the  lung  ;  it  may 
be  seated  at  the  upper  part  of  the  pleural  cavity,  such  as  the  infra-clavicu- 
lar region  ;  or  it  may  occupy  the  space  between  the  lobes.  In  many  cases 
the  locahsation  of  the  disease  is  due  to  old  adhesions  resulting  from  a  pre- 
vious attack,  so  that  the  fluid  thi'own  out  is  prevented  from  gravitating 
,  downwards  or  spreading  over  the  general  cavity  of  the  pleura ;  but  in 
others  no  history  of  a  similar  illness  can  be  discovered. 

In  ordinary  cases  of  loculated  pleiuisy  the  general  symptoms  do  not 
differ  from  those  met  with  in  the  more  common  form  of  the  disease.  But 
the  physical  signs  are  more  characteristic.  Over  the  collection  of  fluid  the 
percussion-note  is  completely  dull,  with  great  sense  of  resistance  ;  the  res- 
piration is  weak,  and  may  be  of  bronchial,  blowing,  or  cavernous  quality  ; 
there  is  seldom  any  friction-sound  to  be  heard,  and  the  vocal  resonance  is 
ordinarily  suppressed.  Such  signs  may  be  discovered  over  the  whole  front 
of  the  chest ;  they  may  be  hmited  to  the  infra-clavicular  or  infra-mammary 
regions  ;  they  may  be  found  in  the  scajDular  region  behind,  or  at  the  lower 
j)art  of  the  axillary  region  at  the  side.  The  most  difiicult  to  detect  of  these 
partial  pleurisies  is  no  doubt  that  variety  in  which  the  inflammation  and 
effusion  are  confined  to  an  interlobar  space.  In  such  a  case  there  may 
be  considerable  retraction  of  the  side  from  compression  of  the  lung  ;  or  the 
physical  signs  may  occupy  so  limited  an  area  as  to  escape  recognition,  and 
there  may  be  no  displacement  of  the  heart.  After  the  fluid  has  become 
purulent,  the  cough,  the  wasting,  and  the  cachectic  appearance  of  the  child, 
coupled  with  the  insignificant  character  of  the  physical  signs,  often  suggest 
tuberculosis. 

Diaphragmatic  pleurisy  is  rare  in  the  child.  The  disease  begins  sud- 
denly with  a  severe  pain  shooting  across  the  chest  and  great  oppression'  of 
breathing.  The  child  sits  up  in  bed  with  a  distressed  face.  His  skin  is 
hot,  and  every  attempt  to  draw  a  deep  breath  is  a  cause  of  gi-eat  suffering. 
The  physical  signs  are  often  very  indefinite  ;  but  usually  some  dulness 
may  be  discovered  at  the  extreme  base  on  one  side,  with  weak  breathing  ; 
and  often  after  a  day  or  two  the  ordinary  signs  of  pleurisy  can  be  detected 
at  the  lower  part  of  the  same  side  ;  for  diaphi'agmatic  pleui'isy  rarel}'  re- 
mains hmited  to  the  diaphragm  in  early  life. 

Tuberculous  Pleurisy. — When  plei;risy  occurs  as  a  consequence  of 
tuberculosis  it  is  usually  double  ;  "but  every  case  of  double  pleurisy  in 
the  child  is  not  necessarily  tuberculous.  Nor,  again,  in  every  case  of 
pleurisy  in  a  tuberculous  subject  is  the  serous  inflammation  always  secon- 
dary to  the  diathetic  disease.     It  has  been  akeady  stated  that  tuberculosis 


PLEURISY — VAEIETIES — DIAGISTOSIS.  453 

is  a  common  sequel  of  empyema  of  long  standing  ;  and  a  purulent  collec- 
tion in  the  chest  precedes  tuberculosis  much  more  often  than  it  follows  it. 
In  cases  where  j^leurisy  is  met  with  as  a  secondary  disease  the  inflamma- 
tion is  usually  of  the  plastic  variety  ;  although  sometimes  there  is  also 
serous  or  purulent  effusion  in  the  chest-cavity.  We  can  only  say  positively 
that  tuberculosis  is  the  primary  disease  when  the  symptoms  of  the  con- 
stitutional malady — wasting,  moderate  fever,  loss  of  colour  and  strength, 
a  distressed  expression  of  face  and  occasional  cough — have  preceded  by  a 
definite  interval  the  local  signs  of  serous  inflammation. 

When  tuberculosis  follows  empyema  the  temperature,  if  it  had  subsided, 
rises  to  between  101°  and  102°  or  higher  every  evening,  falling  again  to 
between  99°  and  100°  in  the  morning.  The  child  loses  flesh,  colour,  and 
strength  more  rapidly  than  the  condition  of  his  chest  is  sufficient  to  ex- 
plain. His  face  is  haggard  and  careworn  ;  his  skin  harsh  and  dry  ;  often 
diarrhoea  comes  on  ;  sometimes  he  vomits  ;  his  belly  swells ;  and  an  attack 
of  basic  meningitis  usually  brings  the  illness  rapidly  to  a  close. 

Complications. — Besides  tubei'culosis  and  amyloid  disease  of  organs 
(which  have  been  already  alluded  to),  there  are  other  complications  which 
may  be  present  in  cases  of  pleurisy.  Pericarditis  is  not  uncommon  as  an 
accompaniment  of  the  pleural  inflammation.  This  subject  is  referred  to 
elsewhere  (see  page  158).  Moreover,  serous  inflammation  in  the  chest  some- 
times spreads  upwards  from  the  peritoneum.  More  often,  howevei',  it  pen- 
etrates downwards  through  the  diaphragm  to  the  abdominal  cavity.  It  is 
then  usually  fatal  (see  page  685). 

Diagnosis. — On  account  of  the  resemblance  of  its  physical  signs  to  those 
of  pneumonia,  pleurisy  is  often  mistaken  for  that  disease.  The  difficulty 
in  making  the  distinction  is  due  principally  to  the  absence  of  vocal  fremitus 
in  the  child  ;  to  the  occasional  loud  blowing  or  tubular  breathing  which  is 
often  heard  over  the  seat  of  dulness ;  and  to  the  crackling  character  of  the 
friction,  which  suggests  rather  an  intra-pulmonary  crepitation  than  a 
pleural  rub.  In  order  to  distinguish  between  the  two  diseases  we  must 
take  into  account  the  mode  of  invasion,  the  nature  of  the  symptoms,  and 
the  character  of  the  j)hysical  signs  ;  for  in  all  these  points  gi'eat  differences 
are  to  be  observed. 

The  occurrence  of  pain  in  the  side  and  fever,  followed  after  an  interval 
by  cough,  is  characteristic  of  pleurisy.  In  pneumonia  cough  is  usually 
present  from  the  beginning,  and  pain  in  the  side,  unless  pleurisy  accom- 
pany the  inflammation  of  the  lung,  is  moderate  or  absent.  The  after 
symptoms  also  are  different.  In  pleurisy  the  cough  is  dry  and  painful ; 
the  pulse-respiration  ratio  is  unaltered  ;  the  face  is  jDale  or  congested  at 
first,  afterwards  straw  yellow  ;  and  there  is  little  loss  of  muscular  strength. 
In  pneumonia  the  cough  occurs  in  short  hacks,  accompanied  in  the  older 
children  by  the  expectoration  of  rusty  sputum  ;  the  pulse-respiration  ratio 
is  perverted  ;  the  face  has  a  bright  flush  on  the  cheeks  ;  and  muscular 
prostration  is  a  marked  feature.  The  jDhysical  signs  also  are  distinctive. 
In  pleurisy  the  chest,  even  if  not  enlarged  to  the  measuring  tape,  is  square 
in  outline  ;  the  heart's  apex  is  displaced  ;  the  dulness  is  complete,  the  note 
being  perfectly  flat,  and  the  sense  of  resistance  to  the  finger  extreme  ;  the 
respiratory  sounds,  although  they  may  be  as  tubular  as  in  a  case  of  typical 
pulmonary  inflammation,  are  always  less  loud  at  the  base  than  above  ;  and 
the  crackling  friction  has  not  the  "jouffy"  character  of  pneumonic  crepita- 
tion. The  chief  difference,  however,  consists  in  the  fact  that  in  an  ordinary 
case  of  pleurisy  the  abnormal  physical  signs  are  found  both  at  the  back 
and  front  of  the  affected  side.     In  pneumonia  there  is  no  displacement  of 


454  DISEASE   IlSr    CHILDKElSr. 

the  heart's  apex ;  the  duhiess  is  not  complete  ;  the  sense  of  resistance, 
although  greater  than  natural,  is  only  moderately  increased  ;  the  resonance 
of  the  voice  at  the  angle  of  the  scapula  is  never  segophonic  ;  and  the 
physical  signs,  unless  the  inflammation  occupy  the  apex  of  the  lung,  are 
limited  to  the  anterior  or  posterior  aspect  of  the  chest,  and  are  only  in 
very  extreme  cases  found  over  the  whole  of  the  affected  side. 

Between  an  ordinary  case  of  pleiu'itic  effusion  aud  an  ordinary  case  of 
lobar  inflammation  of  the  lung  the  differences  are  so  great,  that  there  is 
little  difficulty  in  making  the  distinction.  But  to  decide  between  a  local- 
ised pleurisy  and  a  case  of  lobar  pneumonia  is  not  so  easy.  Still,  even 
here,  by  attention  to  the  mode  of  invasion  and  the  character  of  the  symp- 
toms, and  by  remarking  that,  although  limited  to  one  aspect  or  one  region 
of  the  chest,  the  percussion-note  is  complete!}'  toneless,  the  sense  of  re- 
sistance is  extreme,  and  the  weak  breath-sound  is  not  accompanied  by  cre- 
pitation at  the  borders  of  the  dull  area  (for,  in  localised  pleurisy  friction  is 
rarely  to  be  heard),  we  can  usually  come  to  a  satisfactory  conclusion.  The 
very  fact  of  these  physical  signs  continuing  for  a  considerable  time  un- 
changed is  in  itself  a  strong  argument  in  favour  of  the  pleuritic  nature  of 
the  complaint.  Dr.  Wilks,  indeed,  lays  it  down  as  a  rule  that  local  dul- 
ness  with  distant  tubular  breathing,  or  absence  of  breath-sound,  persist- 
ing after  an  inflammatory  attack  in  the  chest,  indicates  the  presence  of  a  lo- 
cal empyema  ;  and  if  no  adventitious  sounds  accompany  the  respiration,  we 
may,  no  doubt,  commit  ourselves  to  this  diagnosis  without  hesitation. 

Ordinary  cases  of  catarrhal  pneumonia,  where  the  inflammation  occu- 
pies both  lungs,  can  rarely  resemble  pleurisy  closely  enough  to  be  con- 
founded with  it.  Unless  the  catarrhal  pneumonia  be  accompanied  by  plastic 
pleurisy,  the  percussion-note  is  only  moderately  dull ;  the  resistance  is  little 
increased  ;  there  is  usually  loud  tubular  or  cavernous  breathing  at  the  ex- 
treme base  from  dilatation  of  the  bronchi ;  and  the  profuse  crepitation  has 
a  crisp  metallic  quality  which  bears  little  resemblance  to  the  sound  pro- 
duced in  an  inflamed  pleura.  It  is  in  cases  where  the  catarrhal  inflamma- 
tion occurs  secondarily  in  a  lung  which  is  ah-eady  the  seat  of  fibroid  indura- 
tion that  a  real  difficulty  is  found.  Here  the  inflammation  is  confined  to 
one  lung  and  spreads  rapidly,  so  as  to  involve  the  whole  thickness  of  the 
organ.  Consequently,  the  lung,  already  indurated  by  the  fibroid  change, 
gives  a  character  to  the  percussion-note  which  is  indistinguishable  from 
that  produced  by  pleuritic  effusion  ;  and  we  find  a  complete,  toneless  dul- 
ness  with  marked  sense  of  resistance  all  round  the  affected  side — both  at 
the  back  and  front.  In  the  indurated  lung,  however,  the  tubular  or  cav- 
ernous breath-sound  is  accompanied  by  a  large  metaUic  bubbhng  rhonchus. 
In  pleurisy  the  breathing  is  usually  accompanied  by  no  adventitious  sound  ; 
but  if  a  httle  crepitating  friction  be  present,  it  is  much  drier  in  character, 
and  has  not  the  loud  ringing  resonance  which  is  given  to  a  rhonchus  gene- 
rated in  a  rigid  dilated  air-tube.  In  both  the  vocal  resonance  may  be 
bronchophonic,  but  in  pneumonia  it  never  has  an  a?gophonic  quality. 

Collapse  of  the  lung  in  exceptional  cases  may  jDresent  a  very  close  re- 
semblance to  pleurisy  ;  but  the  dulness  on  percussion  is  rarely  so  complete, 
and  the  sense  of  resistance  seldom  so  great  in  collapse  as  in  fluid  effusion. 
The  resistance  in  the  latter  case  to  the  percussing  finger  is  an  element  of 
the  utmost  importance  in  the  diagnosis,  and  is  only  equalled  in  point  of 
intensity  by  a  fibroid  indiu-ation  of  the  lung  with  superadded  catarrhal 
pneumonia,  as  ah-eady  described. 

With  regard  to  the  varieties  of  pleurisy,  it  is  often  very  difiicult  to  say 
whether  the  fluid  is  serous  or  purulent,  or,  indeed,  whether  the  physical 


PLEUEISY — DIAGNOSIS— PROG^^OSIS.  455 

signs  are  not  due  to  a  coating  of  lymph  ^^'itllout  liquid  effusion  at  all.  If 
a  change  in  the  percussion-note  and  the  character  of  the  physical  signs 
follows  a  change  in  the  position  of  the  patient,  the  presence  of  fluid  is 
placed  beyond  the  possibihty  of  doubt.  But  if  no  such  characteristic  sign 
of  fluid  can  be  discovered,  it  is  no  proof  that  fluid  is  not  present.  The 
effusion  may  be  kept  in  place  by  adhesions,  or  there  may  be  sufficient  lymph 
coating  the'pleiu-a  to  produce  a  dull  percussion-note,  although  fluid  be  no 
longer  in  contact  with  the  wall  of  the  chest  at  the  point  of  examination. 
An  segophonic  resonance  of  the  Yoice  is  a  certain  sign  of  efliasion  ;  but  its 
absence  is  by  itself  no  sufiicient  proof  of  the  absence  of  fluid.  If,  however, 
the  outline  of  the  affected  side  be  elliptical  and  the  heart's  apex  in  the 
natural  position ;  if  the  intercostal  spaces  sink  in  normally,  the  percussion- 
note  be  duU  in  all  changes  of  position,  the  respiration  be  weak  over  the 
affected  side  without  blowing  quality,  and  the  vocal  resonance  not  at  aU 
fegophonic,  it  is  almost  certain  that  no  fluid  is  present.  Even  here,  how- 
ever, no  positive  conclusion  can  be  arrived  at,  for  with  such  signs  there  may 
be  an  encysted  collection  of  pus  at  almost  any  part  of  the  chest. 

The  distinction  between  a  serous  and  a  purulent  effusion  is  very  diffi- 
cult. No  information  can  be  gained  from  the  temperature,  for  this  may  be 
elevated  or  not  without  reference  to  the  character  of  the  fluid.  It  is  often 
high  with  a  serous  effusion  and  perfectly  normal  with  a  large  purulent 
collection  in  the  chest.  Again,  the  physical  signs  are  the  same  whatever 
be  the  nature  of  the  plem-al  contents  ;  for  Bacelli's  sign  {i.e.,  the  clear  and 
articulate  conduction  of  the  whispered  voice  to  the  chest-wall  as  indicative 
of  serous  and  exclusive  of  purulent  effusion)  has  not  unfortunately  the 
value  attributed  to  it  by  this  physician.  The  tint  of  the  face,  however,  if 
the  complexion  have  assumed  the  straw  yellow  hue,  although  not  a  decisive 
proof,  is  very  suggestive  of  empyema  ;  and  marked  clubbing  of  the  finger- 
ends,  according  to  Dr.  T.  Barlow,  is  never  the  consequence  of  serous  effu- 
sion. Li  every  case  of  doubt  an  exploratory  puncture'  with  the  hypoder- 
mic injection  syringe,  by  withdrawing  a  specimen  of  the  fluid,  will  at  once 
decide  the  question. 

Hydrothorax  is  as  a  rule  readily  distinguished  from  pleurisy  by  noting 
the  evidences  which  are  always  present  of  interference  with  the  general  cir- 
culation. Dropsy  of  the  pleura  is  almost  always  a  part  of  general  anasarca. 
There  is  disease  of  the  heart  or  kidneys  ;  the  effusion  occurs  on  both  sides 
simultaneously  ;  and  there  is  also  ascites  or  more  or  less  general  oedema. 

Prognosis. — In  cases  of  pleurisy  the  prognosis  depends  in  a  great  meas- 
ure upon  the  age  and  constitution  of  the  child.  Under  the  age  of  six  months 
the  disease  is  a  very  serious  one,  and  often  ends  in  death.  After  that  early 
period  the  prognosis  is  good,  as  a  rule,  if  the  child  be  not  the  subject  of  a 
diathetic  taint.  The  scrofulous  habit  is,  however,  a  distinctly  unfavourable 
element,  for  although  the  disease  may  eventually  end  happily,  the  fluid 
tends  to  become  quickly  purulent ;  the  febrile  excitement  is  usually  great ; 
interference  with  nutrition  is  marked  ;  and  not  unfrequently  the  fluid  is 
continuaUy  reproduced  as  often  as  it  is  evacuated. 

If  the  fluid  remain  serous,  recovery  is  certain  unless  the  fluid  accumu- 
late to  such  a  degree  as  to  dislocate  the  heart  and  interfere  with  the  passage 
of  the  blood  through  the  large  vessels.  In  such  cases  death  may  occiir  un- 
less the  child  be  rapidly  reheved  by  operation.     When  the  fluid  has  become 

'  It  may  be  observed,  Trith  regard  to  making  exploratory  punctures,  thattbe  operation 
is  less  painful  if  a  spot  be  selected  where  the  skin  is  thin,  as  in  the  axilla,  than  if  the 
needle  be  introduced  in  the  back,  where  tlie  cutis  is  thick  and  resistant. 


456  DISEASE  m   CHILDREN. 

purulent  the  prospect  is  more  serious,  but  less  so  in  childliood  than  in 
after  years  ;  for  if  proper  measures  be  adopted  a  large  majority  of  these 
cases  recover.  A  high  temperature  is  an  unfavourable  sign,  and  the  con- 
tinuance of  the  pyrexia  after  discharge  of  the  piu-ulent  matter  by  operation 
should  occasion  great  anxiety.  Still,  even  in  these  cases  recovery  often 
foUovs^s.  Again,  the  sudden  sinking  of  the  temperature  to  a  point  below 
the  level  of  health  is,  as  WunderHch  has  pointed  out,  a  sign  of  unfavour- 
able impori. 

If  the  emjDyema  burst  spontaneously  thi'ough  the  chest-wall,  recovery 
rarely  takes  place  unless  the  opening  be  seated  in  a  lower  intercostal 
space,  or  unless  an  artificial  opening  be  established  in  a  more  suitable 
position.  Spontaneous  ciu-e  is  more  likely  to  follow  evacuation  through  a 
bronchus  ;  and  a  large  projoortion  of  these  cases  get  well.  Still,  if  the  cir- 
cumstances are  such  that  retention  of  purulent  matter  takes  place,  the 
child,  if  left  alone,  may  sink  exhausted. 

Fetor  of  the  pus  is  a  bad  sign.  Unless  prompt  antiseptic  measiu'es  are 
adopted,  these  cases  always  end  fatally. 

Secondary  pleurisy  is  much  more  dangerous  than  the  primary  form  of 
the  disease.  The  fluid  is  more  hkely  to  become  purulent  at  an  early  date  ; 
and  the  child,  already  weakened  by  his  first  illness,  is  in  an  unfavourable 
condition  to  support  the  exhausting  influence  of  a  chronic  empyema  upon 
his  nutrition. 

Treatment. — A  child  attacked  by  acute  pleurisy  should  be  at  once  put 
to  bed,  for  absolute  rest  is  of  the  highest  importance.  A  febrifuge  mix- 
ture should  be  ordered,  and  the  diet  should  consist  of  milk  and  broth. 
If  the  pain  in  the  side  be  severe,  a  leech  or  two  may  be  apphed  if  the  child 
is  robust ;  or  a  hypodermic  injection  may  be  given  containing  one-twelfth 
of  a  grain  of  morphia  for  a  child  of  foiu'  years  of  age.  A  firm  bandage 
round  the  chest  is  often  successful  in  giving  great  relief ;  and  a  thick  layer  of 
wadding  around  the  affected  side  is  useful  for  the  sake  of  warmth.  Some 
physicians  advocate  a  careful  strapping  of  the  chest  over  the  affected  lung 
with  broad  strijDS  of  adhesive  plaster.  I  have  made  use  of  this  plan,  but 
cannot  say  I  have  noticed  any  distinct  advantage  from  its  employment.  In 
diaphragmatic  pleurisy  where  the  pain  is  severe,  a  firmly  apphed  bandage 
to  the  abdomen,  so  as  to  limit  the  action  of  the  diaphragm,  often  affords 
ease.  The  bowels,  if  confined,  must  be  relieved  by  mild  aperients,  such 
as  the  liquid  extract  of  rhamnus  frangula  or  the  compound  hcjuorice 
powder  ;  but  violent  pui'gation  is  hurtful  and  should  be  avoided.  Mer- 
cury, the  favourite  remedy  in  former  days,  is  now  seldom  recommended. 
Still,  in  some  cases,  one  grain  of  gray  powder  given  twice  a  day,  with  an 
equal  quantity  of  quinine,  or  with  five  grains  of  the  peroxide  of  iron,  has 
sometimes  seemed  to  me  to  be  beneficial.  Iodide  of  potassium  is,  however, 
usually  to  be  preferred,  and  this  salt,  given  in  full  doses,  I  believe  to  be  of 
distinct  advantage  to  the  patient.  I  am  in  the  habit  of  ordering  for  a 
child  of  four  years  old,  five,  eight,  or  ten  gi-ains  of  the  iodide,  to  be  taken 
every  six  hours,  and  look  upon  the  remedy  given  in  such  doses  as  a  valu- 
able promoter  of  absoiption.  The  internal  remedy  should  be  always  sup- 
plemented by  counter-irritatioD  of  the  chest-wall.  Directly  the  tempei'a- 
ture  falls,  or  earlier  if  effusion  appears  to  have  ceased,  the  liniment  or 
tincture  of  iodine  (according  to  the  sensitiveness  of  the  skin)  should  be 
painted  over  a  limited  surface  eveiy  night.  This  application  is  most  use- 
ful if  applied  over  an  area  of  two  or  three  inches  in  diameter — repainting 
the  same  on  each  occasion.  When  the  skin  begins  to  look  dry  and  cracked, 
another  spot  is  selected,  and  the  j)rocess  is  repeated  regularly  as  before. 


PLEURISY — TEEATMENT.  457 

If,  after  a  week,  the  fluid  remains  stationary,  Tvitliout  sign  of  absorp- 
tion it  is  better  to  change  from  the  iodide  to  a  chalybeate,  or  to  add  five 
or  six  grains  of  the  tartrate  of  iron  to  the  mixture.  In  scrofulous  children, 
when  effusion  has  ceased,  it  is  advisable  to  im^Drove  the  diet ;  and  pounded 
meat,  strong  meat  broths,  yolks  of  eggs,  and  moderate  quantities  of  stim- 
ulant are  usually  required. 

If  at  the  end  of  a  fortnight  the  effusion  has  been  unchanged  in  amount, 
it  is  probably  purulent.  An  exploratory^  puncture  should  be  made  with  a 
fine  needle  syringe,  and  if  pus  be  withdrawn,  measures  should  at  once  be 
taken  to  evacuate  the  chest.  If  the  fluid  is  found  to  be  serous  it  is  ad- 
visable to  wait  for  a  few  days,  for  this  small  operation  and  the  abstraction 
of  even  the  limited  quantity  withdrawn  by  the  test  puncture,  may  act  as  a 
stimulus  to  absorption  and  be  followed  by  the  rapid  removal  of  the  fluid 
by  natural  means.  At  the  same  time  the  quantity  of  Hquid  taken  by 
the  child  should  be  restricted  ;  for  a  dry  diet  in  such  cases  by  stinting 
the  blood  of  fluid  often  greatly  promotes  the  action  of  the  absorbent 
vessels. 

Often  when  effusion  is  undoubtedly  present  the  introduction  of  the 
exploring  needle  is  followed  by  no  appearance  of  fluid ;  or  although  pus 
has  been  withdrawn  by  the  test  puncture  the  aspirator  needle  is  intro- 
duced without  any  result.  The  instrument  may  have  entered  the  chest- 
cavity  at  a  spot  where  the  lung  is  adherent  to  the  parietes,  or  the  layer 
of  false  membrane  Hning  the  pleura  may  be  so  thick  that  the  needle 
fails  to  penetrate  into  the  sac.  In  choosing  a  place  for  the  puncture 
it  is  advisable  to  select  one  where  the  dulness  is  complete  ;  and  it  is 
well,  as  Dr.  Allbutt  has  suggested,  to  look  for  a  spot  where  there  is 
bulging  of  the  intercostal  space,  as  here  the  false  membranes  are  scanty 
and  thin.  Often  it  is  necessary  to  puncture  several  times,  on  each  oc- 
casion selecting  a  fresh  spot,  before  we  succeed  in  obtaining  evidence  of 
fluid. 

In  some  cases  the  difficulty  met  with  in  withdrawing  the  fluid  is  due  to 
rigidity  of  the  chest-walls.  If  the  walls  of  the  empyema  cavity  cannot 
collapse,  there  is  no  expolsive  force  to  drive  out  the  fluid.  As  Mr.  K.  W. 
Parker  has  pointed  out,  the  pleural  cavity  is  emptied  by  the  pressure  of 
the  atmosphere  acting  in  three  different  ways.  It  acts  on  the  condensed 
lung  causing  it  to  re-expand,  on  the  diaphragm  causing  it  to  ascend,  and 
on  the  thoracic  Avail  causing  it  to  fall  in.  If  for  any  reason  pressure  can- 
not be  brought  to  bear  on  the  confined  fluid,  no  amount  of  suction  force 
will  have  any  power  of  withdravnng  the  liquid  contents  of  the  chest.  In 
not  a  few  cases,  the  aspirator  being  found  to  be  useless  and  no  fluid  ap- 
pearing after  repeated  punctures,  we  are  forced  to  incise  the  chest  and 
insert  a  drainage-tube  in  order  to  evacuate  the  pleural  cavity.  ]\Ii'.  Parker 
has  devised  an  apparatus  to  meet  this  difficulty,  by  means  of  which  filtered, 
warmed,  and  carbolised  air  can  be  pumped  into  the  upper  part  of  the  chest 
while  fluid  passes  out  through  the  aspirator  needle  introduced  into  the 
lower  part. 

The  above  are  not  the  only  causes  by  which  thoracentesis  is  rendered 
difficult.  Large  thick  flakes  of  lymph  may  be  present  and  obstruct  the 
opening  of  the  needle  or  drainage-tube.  A  child,  aged  one  year  and  eight 
months,  was  admitted  under  my  care  into  the  East  London  Children's 
Hospital,  with  the  physical  signs  of  a  large  effusion  on  the  left  side  of  the 
chest.  An  exploratory  puncture  showed  pus  to  be  present.  Many  attempts 
were  made  to  aspirate  the  chest,  but  only  small  quantities  of  pus  could  be 
withdrawn.    After  repeated  failures  it  was  determined,  in  consultation  with 


458  DISEASE  i:sr  childeen". 

my  colleague  Mr.  Parker,  to  incise  the  wall  and  put  in  a  drainage-tube. 
This  was  done,  but  even  then  pus  did  not  flow  freely.  ]\Ir.  Parker  then 
put  in  his  finger  through  the  opening  in  the  chest-wall  and  found  large 
flakes  of  thick  membraniform  lymph  which  had  to  be  removed  by  the  for- 
ceps. A  large  quantity  of  pus  was  then  expelled,  containing  smaller  flakes 
of  lymph,  besides  pultaceous  matter.  Listerian  precautions  were  observed 
and  the  case  did  well. 

When  the  effusion  of  fluid  has  accumulated  to  such  a  degree  as  seriously 
to  hamper  the  circulation  and  produce  a  cyanotic  tint  of  the  skin,  the 
aspirator  should  be  used  at  once,  as  instant  rehef  is  required  to  avert  death. 
If,  however,  the  effusion  be  more  moderate  and  no  danger  be  anticipated, 
the  question  of  operative  interference  will  depend  upon  the  nature  of  the 
pleural  contents,  and  the  presence  or  absence  of  signs  of  absorption.  If 
the  fluid  be  purulent  there  is  no  likelihood  of  a  spontaneous  cure  by  ab- 
sorjption.  Therefore  retention  of  the  purulent  contents  can  in  any  case 
only  do  harm  ;  and  in  children  with  tubercular  or  scrofulous  tendencies  a 
collection  of  pus  should  not  be  allowed  to  remain  in  the  chest  a  day  longer 
than  is  necessary.  Even  if  the  fluid  be  still  serous,  it  is  well  to  remove  it 
if  after  three  weeks  no  sign  of  absorption  has  been  noticed.  In  many  of 
these  cases  the  serous  fluid  is  not  renewed  after  emptying  the  chest ;  and 
often  if  only  a  portion  of  the  contents  be  evacuated  the  remainder  is 
rapidly  taken  up  by  the  absorbent  vessels. 

In  cases  of  empyema  it  is  best  in  the  first  instance  to  employ  the  aspi- 
rator, as  sometimes  after  the  chest-cavity  has  been  evacuated  by  this  means 
the  fluid  is  not  reproduced.  During  the  ojperation  the  chUd  should  be  in 
a  semi-i'ecumbent  position,  supported  by  the  nurse,  and  the  needle  should 
be  introduced,  as  recommended  by  Bowditch,  in  an  interspace  immediatelv 
below  the  inferior  angle  of  the  scapula,  unless  the  empyema  be  loculated. 
The  operation  often  provokes  cough  ;  but  this  may  be  disregarded  unless 
it  grow  excessive,  in  which  case  the  needle  may  be  withdrawn.  If  there 
be  any  sign  of  faintness,  we  should  at  once  remove  the  aspu'ator  and  close 
the  wound. 

Sudden  death,  although  fortunately  a  very  uncommon  catastrophe,  is 
sometimes  a  consequence  of  the  rapid  withdrawal  of  fluid  from  the  chest. 
The  accident  may  arise  from  syncope,  from  rapid  interference  with  the 
function  of  the  healthy  lung,  or  from  cerebral  embolism.  If  the  effusion 
have  been  copious  enough  to  produce  marked  cardiac  displacement  and 
interfere  with  the  circulation  through  the  large  vessels,  the  muscular  sub- 
stance of  the  heart  may  be  in  a  state  of  temporary  mal-nutrition  from  having 
been  supplied  for  some  time  with  imperfectly  purified  blood.  The  sudden 
withdrawal  of  the  pressure,  combined  with  the  slight  shock  of  the  opera- 
tion, may  so  impress  the  weakened  organ  as  completely  to  paralyse  its' 
action  ;  or  if  this  be  borne  without  result,  a  sudden  movement  of  the  pa- 
tient which  throws  extra  work  upon  the  cu'culatory  centre  may  prove 
fatal. 

Death  sometimes  occurs  through  asphyxia.  The  disappearance  of  fluid 
from  the  pleura  is  followed  by  an  afflux  of  blood  to  the  capillaries  not  only 
of  the  lately  compressed  lung,  but  also  of  that  on  the  sound  side  ;  for  the 
latter  has  been  likewise  reheved  from  pressure  by  the  return  of  the  heart 
and  mediastinum  to  their  normal  position.  If  the  afflux  of  blood  becomes 
a  distinct  congestion,  acute  oedema  may  result,  unless  the  vessels  retain 
sufficient  tonicity  to  enable  them  to  resist  the  abnormal  pressure.  Again, 
cerebral  embolism  may  occur,  as  in  a  case  reported  by  M.  Vallin,  in  which 
this  observer  attributed  the  catastrophe  to  the  sudden  disengagement  of 


PLEURISY — TREATMENT.  459 

fibrinous  clots  which  had  formed  in  the  puhnonary  veins  of  the  affected 
side.  Such  clots  are  Hable  to  become  detached  as  a  consequence  of  ex- 
pansion of  the  lung,  of  a  sudden  movement,  or  of  washing  out  of  the  pleu- 
ral cavity. 

If  after  one  or  more  applications  of  the  aspirator  we  find  that  purulent 
fluid  is  always  reproduced,  or  if  the  fluid  withdrawn  is  fetid,  it  is  better  to 
make  an  opening  in  the  chest  and  introduce  a  drainage-tube.  Opinions 
are  divided  as  to  whether  a  single  or  double  opening  is  to  be  preferred. 
If  a  single  opening  allows  of  perfect  evacuation  of  the  pleural  cavity,  it 
seems  to  be  preferable  to  a  double  aperture,  for  the  drainage-tube  passing 
from  one  opening  to  the  other  may,  as  Dr.  Allbutt  has  suggested,  act  as  a 
seton  and  keep  up  a  constant  irritation.  If  a  single  opening  be  made,  the 
spot  selected  should  be  at  some  point  on  a  level  with  the  loAver  angle  of 
the  scapula.  One  end  of  the  drainage-tube  should  be  passed  through  the 
opening,  and  the  other  may  be  allowed  to  dip  into  a  large  bottle  half  full 
of  water.  The  operation  should  be  performed  with  antiseptic  precautions. 
If  chloroform  be  given,  great  care  must  be  exercised  in  its  administration. 
It  is  better  to  do  without  anaesthetics  and  produce  local  insensibility  by 
freezing  the  skin  at  the  site  of  the  operation. 

After  the  tube  has  been  inserted  the  chest  should  be  bound  round  vnth 
an  antiseptic  binder,  and  the  pleural  cavity  may  be  left  to  drain  itself.  It 
will  not  be  necessary  to  wash  it  out  with  disinfecting  solutions  unless  signs 
of  decomposition  have  been  noticed.  If,  however,  the  pus  which  flows 
after  the  operation  is  fetid,  injections  of  a  solution  of  iodine  may  be  em- 
ployed, diluting  one  drachm  of  the  tincture  with  one  ounce  of  water  ;  or 
carbolic  acid  may  be  used  diluted  with  thirty  times  its  bulk  of  water.  This 
measure  will  not  be  required  when  the  pus  continues  to  be  perfectly  sweet. 
In  such  cases  the  introduction  of  antiseptic  solutions  seems  to  keep  up 
an  irritation  which  it  is  desirable  to  avoid.  Moreover,  the  operation  is 
usually  distressing  to  the  patient,  and  is  not  without  danger,  for  syncope 
and  other  alarming  symptoms  have  sometimes  been  seen  to  follow  the  in- 
troduction of  the  fluid.  In  cases  where  the  empyema  is  fetid,  Mr.  R  W. 
Parker  recommends  a  double  opening  to  be  made  in  the  chest- wall  through 
which  the  drainage-tube  can  be  threaded,  and  prefers,  to  injections  of  an 
antiseptic  fluid,  placing  the  child  daily  in  a  warm  bath  with  sufficient 
depth  of  water  to  cover  the  upper  opening.  The  water  can  be  medicated, 
if  desired,  by  a  weak  antiseptic  solution.  It  is  needless  to  say  that  all  in- 
struments used  in  operation  upon  such  cases  should  be  scrupulously  clean 
and  be  carefully  disinfected  before  use. 

Complete  drainage  of  the  cavity  is  followed  in  most  cases  by  great  im- 
provement in  the  condition  of  the  child.  His  temperature,  if  it  had  been  ele- 
vated, falls  ;  his  appetite  improves  ;  and  if  diarrhoea  had  been  present,  the 
stools  become  fewer  in  number  and  much  healthier  in  appearance.  Any  after- 
elevation  of  the  temperature  or  return  of  the  signs  of  distress  and  irritation 
should  lead  us  to  suspect  some  retention  of  fluid  in  the  pleural  cavity,  or  the 
onset  of  some  complication,  such  as  a  secondary  tuberculosis.  In  the  first 
case  it  will  be  well  to  wash  out  the  chest  thoroughly.  In  the  second,  special 
measures  must  be  resorted  to  for  the  treatment  of  the  complication.  If 
secondary  tuberculosis  have  come  on,  the  prospects  of  the  child  are  most 
gloomy,  and  little  can  be  done  to  arrest  the  downward  progress  of  the  dis- 
ease. 

In  cases  where  the  above  method  of  drainage  fails  to  bring  about 
closure  of  the  cavity,  owing  to  imperfect  expansion  of  the  lung  or  rigidity  of 
the  chest-walls,  which  are  slow  to  adapt  themselves  to  the  diminished  size 


460  DISEASE   IN"   CHILDKElSr. 

of  the  organ,  resection  of  a  portion  of  the  rib  seems  often  to  be  of  advan- 
tage in  helping  the  disease  to  a  favourable  termination. 

In  all  cases  of  chronic  empyema  the  strength  of  the  child  should  be  sup- 
ported by  a  free  supply  of  nourishing  food.  Meat  (pounded  if  necessary) 
strong  meat  essence,  milk,  eggs,  etc.,  should  be  given  in  quantities  such  as 
the  patient  can  digest ;  and  port  wine,  St.  Kaphael  tannin  wine,  or  the 
brandy-and-egg  mixture  should  be  offered  in  sufficient  doses.  Cod-liver 
oil  is  also,  especially  in  children  of  scrofulous  constitution,  an  important 
addition  to  the  treatment. 


CHAPTER  VII. 

COLLAPSE  OF  THE  LUNG. 

CoLiAPSE  of  the  lung  is  a  common  lesion  in  infancy.  In  some  new-born 
babies  the  lungs  after  birth  are  imperfectly  expanded  so  that  the  alveoli 
over  a  larger  or  smaller  area  remain  closed  as  in  the  foetal  state.  This 
variety  is  called  congenital  atelectasis.  In  other  cases,  although  perfect  ex- 
pansion has  been  effected  after  birth,  and  the  respiratory  functions  have 
been  thoroughly  established,  collapse  is  induced  in  the  lung  as  a  conse- 
quence of  disease,  and  a  tract  of  variable  extent  becomes  again  condensed 
and  airless.  The  latter  lesion,  which  is  called  2^ost-7iatal  atelectasis  is  more 
common  than  the  former,  and  indeed  is  one  of  the  most  famihar  of  pul- 
monary lesions  in  the  young  child.  These  varieties  will  be  considered 
separately. 

CONGENITAL  ATELECTASIS. 

This  variety  of  pulmonary  collapse  was  first  described  in  the  year  1832 
by  Dr.  Edward  Jong,  who  gave  it  the  name  which  it  still  retains.  Congen- 
ital atelectasis  rarely  occurs  except  in  feeble  infants,  such  as  have  been 
bom  prematurely,  or  are  the  offspring  of  weakly  mothers,  or  have  entered 
life  under  conditions  unfavourable  to  the  efficient  establishment  of  the  re- 
spiratory functions.  A  tedious  labour  producing  long  compression  of  the 
cord  ;  too  energetic  uterine  contractions  causing  a  too  early  separation  of 
the  placenta  from  the  womb  ;  a  low  temperature  of  the  external  air  ;  a  high 
temperature  with  imperfect  ventilation  and  deficiency  of  oxygen — the  im- 
perfect expansion  has  been  attributed  to  all  these  causes.  In  addition,  the 
presence  of  mucus  or  fluid  in  the  aii'-tubes  may  act  as  a  direct  mechanical 
impediment  to  the  entrance  of  air  and  prevent  the  inflation  of  a  part  of  the 
pulmonary  tissue. 

Morbid  Anatomy. — On  inspection  of  a  lung  which  is  the  seat  of  this 
lesion  the  unexpanded  portion  is  at  once  recognised  by  its  dark  red  or 
purplish  colour,  contrasting  with  the  rosy  tint  of  the  inflated  tissue.  Be- 
ing perfectly  airless,  it  looks  shrunken  and  depressed,  does  not  crepitate 
when  squeezed,  and  feels  tough  and  dense  like  soft  leather.  If  a  portion 
be  cut  out  and  placed  in  water,  it  sinks  instantly  to  the  bottom  of  the 
vessel.  On  examination  of  the  cut  surface  with  a  lens,  the  outline  of  the 
air-cells  may  be  visible ;  but  if  the  child  have  survived  for  some  weeks, 
the  vesicular  structure  can  often  hardly  be  perceived.  The  parts  of  the 
lung  which  thus  remain  airless  after  birth  are  most  commonly  the  least 
bulky  portions,  such  as  the  thin  lower  borders  of  the  lobes,  especially  the 
inferior  lobes  and  the  middle  lobe  of  the  right  lung.  Often,  however,  the 
collapse  is  not  confined  to  these  parts,  but  extends  for  some  distance  over 
the  posterior  surface,  and  penetrates  pretty  deej)ly  into  the  organ. 

If  the  child  die  early,  the  unexpanded  lobules  can  be  readily  inflated 
after  death  by  a  blow-pipe  passed  into  the  bronchus  ;  but  if  life  has  been 


462  DISEASE  iisr  CHILDEEIS'. 

prolonged  for  a  period  of  weeks,  re-inflation  is  not  so  easy  and  may  only 
be  effected  by  the  expenditure  of  considerable  force. 

In  cases  of  congenital  atelectasis  other  parts  besides  the  lungs  often 
remain  in  the  foetal  state.  The  foramen  ovale  is  usually  open,  and  perhaps 
the  ductus  arteriosus  may  still  remain  unclosed. 

Symptoms. — In  a  new-born  infant,  when  expansion  of  the  lungs  is  im- 
jjerfect,  the  child  is  usually  small  and  ill-nourished.  His  appearance  and 
manner  show  great  want  of  power,  and  his  muscles  feel  soft  and  flabby. 
His  complexion  is  dirty  white  or  pale,  with  lividity  about  the  eyelids  and 
mouth.  He  lies  quietly  without  movement,  and  seems  very  apathetic, 
seldom  attempting  to  cry.  If  he  do,  he  utters  only  a  feeble  whimper  and 
never  makes  a  loud  sound.  Often  he  merely  draws  up  the  corners  of  his 
mouth  without  making  any  sound  at  all.  The  fingers  and  toes  are  of  a 
dark  red  or  pui-ple  tint,  and  feel  cool  to  the  touch  ;  indeed,  the  internal 
temperature  of  the  child  is  below  the  normal  level,  and  often  reaches  only 
97.5^  in  the  rectum.  The  respiratory  movements  are  not  laboured  ;  on 
the  contrary,  they  are  shallow  and  short,  and  evidently  expand  the  chest 
very  imperfectly.  As  in  all  cases  where  the  bases  of  the  lungs  fail  to  ex- 
pand in  a  young  child,  the  corresj)onding  ribs  sink  in  to  a  certain  extent 
at  each  inspu-ation.  Still,  on  account  of  the  feebleness  of  the  inspiratory 
movements  the  depression  at  the  bases  is  less  noticeable  than  it  is  in  some 
other  diseases.  When  put  to  the  breast  the  child  is  unable  to  suck,  and 
has  to  be  fed  with  a  syringe  or  a  spoon.  Sometimes  he  cannot  swallow. 
The  pulse  is  very  feeble  and  the  fontanelle  is  more  or  less  deejDly  depressed. 
A  warm  bath  seems  to  re"\T.ve  the  child  for  the  time,  and  even  gives  a  little 
colour  to  the  skin  ;  but  after  removal  the  infant  sinks  into  his  former  de- 
pression. 

An  examination  of  the  chest  furnishes  little  information.  If  the  un- 
expanded  area  is  small,  we  may  detect  no  sign  to  indicate  the  nature  of 
the  lesion.  There  may  be  a  little  want  of  resonance  at  the  bases  of  the 
lungs  posteriorly  ;  but  on  account  of  the  small  size  of  the  thorax  at  this 
period  of  life,  and  the  facihty  with  which  sounds  are  conveyed  from  one 
part  to  the  other,  the  vesicular  murmur  may  appear  to  be  as  loud  at  the 
bases  as  at  any  other  part  of  the  chest.  It  is  only  in  cases  where  the  col- 
lapse is  very  extensive  that  any  supj)ression  or  alteration  of  the  respiratory 
sound  can  be  detected. 

The  after- symptoms  vary  according  to  the  extent  of  the  useless  portion 
of  the  lungs.  If  this  be  considerable,  the  weakness  continues  ;  the  breath- 
ing remains  shallow  and  short ;  lividity  increases ;  the  eyes  are  motionless ; 
the  pupils  dilated,  and  the  skin  is  cool.  Soon  the  temperature  falls  still 
further,  twitches  and  spasmodic  movements  are  noticed  in  the  face  and 
limbs,  and  the  child  sinking  into  a  state  of  stupor,  dies  asphyxiated  on  the 
second,  third,  or  fourth  day. 

In  the  less  severe  cases,  or  in  cases  where  judicious  treatment  has  suc- 
ceeded in  increasing  the  area  of  inflated  tissue,  the  child  at  first  may  seem 
to  be  going  on  well,  although  he  never  exhibits  in  his  movements  the  vigour 
of  one  whose  lungs  are  well  expanded.  His  movements  are  more  or  less 
languid,  and  he  sucks  feebly  or  cannot  be  persuaded  to  take  the  bottle  or 
the  breast.  After  a  time  he  seems  to  grow  weaker  and  can  only  be  kept 
warm  with  difficulty.  His  respirations  get  more  and  more  shallow  and 
his  cry  feebler.  The  child  is  always  sleepy,  and  lies  dosing  with  livid 
mouth  and  eyelids,  the  latter  often  incompletely  closed.  The  fontanelle 
is  depressed.  From  this  point  he  may  sink  gradually  and  die  after  a 
series  of  convulsive  fits,  or  may  be  roused  by  energetic  treatment  which 


COLLAPSE   OF   THE  LITjS^G — SYMPTOMS — PROGlSrOSIS.  463 

again  inflates  the  closed  air-cells.  But  in  such  a  case,  although  the  child 
may  be  apparently  restored,  the  unfavourable  symptoms  usually  return,  and 
it  is  rare  for  the  patient  to  recover.  In  most  cases  after  a  time  remedies 
seem  to  be  useless  and  the  infant  can  no  longer  be  revived.  Thrombosis 
of  the  cerebral  sinuses,  according  to  Stiffen,  is  often  found  in  these  cases. 

Even  in  cases  where  recovery  is  ajDparently  complete,  the  lung  is  not 
always  perfectly  expanded,  and  a  slight  catarrh  may  cause  sudden  and 
unexpected  death.  Mr.  W.  Burke  Kyan  has  related  the  case  of  a  child,  aged 
five  weeks  and  in  good  condition,  who  one  evening  was  noticed  to  cough, 
and  the  next  morning  died  quite  suddenly.  On  examination  of  the  body, 
both  lungs  were  found  to  be  shrunken  and  firmly  contracted  so  as  to 
leave  the  greater  part  of  the  pericardium  exposed.  They  sank  instantly  in 
water  ;  and  when  cut  into  httle  pieces,  not  the  smallest  bit  floated.  An 
examination  with  a  small  lens  showed  no  trace  of  cellular  structure,  and  an 
examination  by  Mr.  Quekett  of  small  sections  with  a  higher  power  dis- 
covered many  of  the  alveoli  to  be  filled  up  by  small  granules  or  cells  which 
rendered  them  solid. 

Cases  of  congenital  atelectasis  which  recover  completely  are  usually 
those  in  which  energetic  treatment  has  been  adopted  within  a  few  hours 
of  birth  and  has  resulted  in  healthy  inflation  of  the  whole  lung.  In  the 
beginning  this  may  be  often  accomplished  ;  but  delay  leads  to  such  change 
in  the  closed  air-cells  that  they  can  be  rarely  sufiiciently  inflated  to  take 
useful  part  in  the  respiratory  process.  Moreover,  from  the  observations  of 
F.  Weber  and  Stiffen,  it  appears  that  in  cases  where  the  child  survives  with 
permanent  atelectasis  of  a  portion  of  the  lungs,  the  constant  obstruction  to 
the  pulmonary  circulation  leads  to  hypertrophy  of  the  right  side  of  the 
heart,  prevents  the  closure  of  the  foramen  ovale  and  ductus  arteriosus,  and 
may  eventually  induce  hypertrophy  of  the  left  auricle  and  ventricle. 

Diagnosis.  — The  history  of  these  cases  reveals  a  constant  state  of  weak- 
ness and  torpor.  This  want  of  power,  combined  with  lividity  of  the  face, 
inability  to  suck,  shallow  breathing,  and  low  temperature,  is  very  suggestive. 
If  in  addition  we  notice  the  signs  and  symptoms  of  imperfect  expansion  of 
the  chest,  and  on  a  physical  examination  fail  to  find  evidence  of  marked 
consolidation,  we  can  have  little  difiioulty  in  ascribing  the  symptoms  to 
their  true  origin. 

Prognosis. — The  prospect  of  recovery  depends  partly  upon  the  cause  of 
the  atelectasis,  partly  upon  the  strength  of  the  child,  and  partly  upon  the 
period  after  birth  at  which  restorative  measures  are  adopted.  If  the  im- 
perfect expansion  of  the  lungs  be  due  to  some  obstacle  in  the  tubes  them- 
selves, or  to  some  temporary  accident  occurring  at  the  time  of  birth,  the 
child's  strength  is  usually  good  and  treatment  employed  promptly  is  gen- 
erally successful.  If,  however,  means  are  not  adopted  early  to  enforce  ex- 
pansion of  the  unused  alveoli,  the  prognosis  is  little  less  unfavourable  than 
when  the  atelectasis  is  due  to  general  weakness  of  the  patient.  In  the 
latter  case  the  chances  of  permanent  improvement  are  not  good,  but  vary 
according  to  the  strength  of  the  child.  The  unfavourable  signs  are  :  in- 
ability to  suck  ;  increasing  lividity  ;  a  sub-normal  and  falling  tempera- 
ture and  great  apathy  of  manner.  If  the  child  ceases  to  be  able  to  swallow, 
or  if  tonic  or  clonic  spasms  are  noticed  in  the  muscles  of  the  face  or  limbs, 
we  can  entertain  little  hope  of  his  recovery. 

Treatment. — When  a  child  is  born  aj)parently  lifeless  after  a  tedious 
labour  measures  must  be  at  once  adopted  to  promote  efficient  expansion 
of  the  lungs.  It  is  important,  however,  that  whatever  is  done  should  be 
done  with  due  deliberation  and  care,  avoiding  unnecessary  hurry  or  vio- 


464  DISEASE  IN   CHILDEElSr. 

lence.  In  a  new-born  infant  the  organs  are  especially  tender,  and  may  be 
fatally  injured  by  heedless  energy.  Cases  have  been  met  with  in  which 
the  liver  and  spleen  have  been  ruptured  by  an  over-zealous  practitioner  in 
his  haste  to  promote  inflation  of  the  lungs.  The  chest  of  a  new-born 
infant  is  in  a  state  of  absolute  airlessness ;  and  therefore  methods  of  resus- 
citation which  depend  for  their  success  upon  elastic  recoil  of  the  chest- 
walls  are  without  any  value.  So,  also,  the  method  of  mouth-to-mouth 
insufflation,  pressing  at  the  same  time  the  larynx  backwards  against  the 
gullet  so  as  to  close  the  latter  passage,  fails  to  introduce  air  into  the  lungs. 
Dr.  F.  H.  Champneys,  from  a  series  of  elaborate  experiments  upon  the 
bodies  of  new-born  infants,  concludes  that  the  best  method  of  resuscitation 
is  that  of  Dr.  Silvester.  The  child  is  laid  on  his  back  on  a  table  with  a 
pillow  under  his  shoulders,  and  the  operator  standing  behind  the  body 
grasps  the  arms  above  the  elbows  and  everts  them.  He  then  in  successive 
movements  raises  the  arms  upwards  by  the  side  of  the  child's  head ;  ex- 
tends them  gently  upwards  and  forwards  for  a  few  seconds  ;  then  turns 
them  down  and  presses  them  gently  and  firmly  for  a  few  moments  against 
the  sides  of  the  chest.  While  this  is  being  done  the  tongue  should  be  held 
forwards  by  an  assistant.  The  movements  should  be  repeated  fifteen  times 
in  the  minute,  and  should  be  continued  for  at  least  half  an  hour  if  no  satis- 
factory result  be  previously  obtained. 

M.  Greult  advocates  placing  the  infant  in  water  as  hot  as  the  hand  can 
bear — which  he  finds  to  be  about  113°  F.— and  employing  artificial  res- 
piration while  the  child  remains  in  the  bath.  He  relates  the  case  of  a 
primipara  who  after  a  tedious  laboiu'  was  delivered  by  forceps.  The 
infant,  when  born,  was  breathless,  cold,  with  scarcely  any  movement  of  the 
heart  and  but  feelDle  pulsation  in  the  cord.  The  child  was  at  once  placed 
in  water  which  felt  burning  hot  to  the  hand,  and  artificial  respiration  was 
begun.  At  the  end  of  one  minute  the  skin  reddened,  and  a  slight  move- 
ment of  the  chest  indicated  the  beginning  of  respiration.  At  the  end  of 
two  minutes  the  child  began  to  cry,  to  breathe,  and  to  move  his  limbs. 

In  cases  where  the  infant  breathes,  but  is  evidently  labouring  under 
imperfect  expansion  of  the  lungs,  he  should  be  warmly  covered  or  even 
wrajDped  in  cotton  wool,  and  kept  perfectly  quiet  in  a  room  heated  to  a  tem- 
perature of  70°  or  75.°  The  best  position  is  that  recommended  by  the  late 
Dr.  C.  D.  Meigs,  viz.,  upon  the  right  side  with  the  head  and  shoulders 
raised  at  an  angle  of  45''.  If  the  patient  cannot  suck  he  should  be  fed  with 
breast  milk  or  some  efficient  substitute,  as  directed  elsewhere  (see  page 
603).  The  food  must  be  given  with  the  syringe  and  elastic  tube  (see  page 
15 ).  Stimulants  are  indispensable.  Five  drops  of  brandy  can  be  given 
in  a  syringeful  of  the  food  every  two,  three,  or  four  hours,  or  the  child  may 
be  fed  with  white  wine  whey.  If  the  lividity  increases  and  other  unfavour-' 
able  signs  are  noticed,  attempts  should  be  made  to  force  the  child  to  cry  or 
gasp  by  slapjDing  the  chest  with  the  corner  of  a  towel  wetted  with  cold 
water.  Emetics  are  also  useful  in  freeing  the  tubes  of  mucus  and  forcing 
the  patient  to  respire  deeply.  Sulphate  of  copper  (a  quarter  of  a  grain 
in  a  teaspoonful  of  water)  is  the  best  form  in  which  they  can  be  given. 
Emetics,  however,  must  not  be  used  if  the  child  is  very  feeble. 

Stimulating  embrocations  rubbed  into  the  chest  are  often  of  service,  and 
immersion  in  a  strong  mustard  bath  (one  ounce  of  mustard  to  each  gallon 
of  water)  until  the  skin  becomes  very  red  is  a  stimulant  of  very  powerful 
efficacy.  The  internal  administration  of  stimulants  should  be  continued  as 
long  as  the  child  is  able  to  swallow.  Unfortunately  in  bad  cases  the  results 
of  all  these  measures  are  far  from  encouraging. 


COLLAPSE   OF   THE   LUNG — TEEATMENT.  465 


POST-NATAL  ATELECTASIS. 

The  form  of  collapse  of  the  lung  which  occurs  in  infants  whose  lungs 
have  been  fully  expanded  at  birth  is  a  very  common  lesion.  It  occurs 
almost  invariably  in  the  course  of  a  pulmonary  catarrh,  and  is  one  of  the 
accidents  which  render  this  form  of  derangement  so  fatal  in  weakly  or 
rickety  children. 

Causation. — The  immediate  cause  of  collapse  of  the  lung  is  the  presence 
in  the  bronchial  tubes  of  mucus  which  the  child  is  unable  to  expel  by  reason 
of  feebleness  of  the  respiratory  apparatus.  Dr.  Gau'dner,  of  Glasgow, 
in  his  treatise  explains  very  clearly  the  mechanism  by  which  exhaustion  of 
the  lobules  is  effected.  In  the  act  of  inspiration  a  plug  of  mucus  is  carried 
inwards  along  a  tube  the  calibre  of  which  is  constantly  diminishing.  When 
the  narrowness  of  the  tube  prevents  further  advance,  the  mucus  forms  a 
plug  which  completely  obstructs  the  channel.  During  expiration  the  plug 
is  slightly  dislodged  so  as  to  permit  of  the  escape  of  some  of  the  air  con- 
tained in  the  lobule  ;  but  at  each  inspiration  it  is  again  drawn  backwards 
so  as  to  close  the  tube  completely  against  any  air  entering  to  replace  that 
which  has  just  escaped.  In  this  manner  after  a  time  the  lobules  beyond 
the  point  of  obstruction  are  completely  exhaustq,d  and  the  tissue  becomes 
shrunken  and  condensed.  Even  if  the  plug  of  mucus  be  completely  im- 
pacted in  the  tube  so  that  it  cannot  be  dislodged  during  expiration,  col- 
laj)se  may  still  occur,  for  the  pent-up  air  in  the  alveoli  is  exposed  to  such 
pressure  by  the  elasticity  and  contractility  of  the  alveolar  parieties  that  it 
is  absorbed. 

The  retention  of  mucus  in  the  tubes  is  the  consequence  of  inability  to 
cough  it  away,  and  any  cause  which  diminishes  the  energy  of  the  inspiratory 
act  increases  the  difficulty  of  drawing  in  air  past  the  impediment  in  the 
bronchus.  New-born  infants  do  not  know  how  to  cough,  for  the  act  of 
coughing  is  only  partly  involuntary.  It  is  in  part  an  eftbrt  of  volition  to 
remove  an  obstacle  to  the  free  passage  of  air  in  the  tubes.  An  infant  who 
has  not  acquired  a  knowledge  of  the  means  by  which  the  impediment  may 
be  expelled,  suffers  the  obstruction  to  remain  without  employing  the  nec- 
essary force  to  effect  its  removal.  Even  if  the  child  knows  how  to  cough, 
he  may  not  have  the  power  to  carry  out  the  act  with  sufficient  energy  to 
make  it  effectual.  In  the  act  of  coughing  a  full  inspiration  is  first  taken. 
The  glottis  is  then  closed,  and  pressure  is  brought  to  bear  upon  the  lungs 
by  the  muscles  of  expiration.  While  this  pressure  is  at  its  height  the 
glottis  is  relaxed,  and  the  rush  of  air  passing  out  carries  with  it  the  mucus, 
which  was  obstructing  the  tubes.  If,  however,  the  lungs  cannot  be  suffi- 
ciently filled,  or  if,  owing  to  weakness  of  the  patient,  the  force  of  the  expi- 
ratory muscles  is  insufficient  to  bring  adequate  pressure  to  bear  upon  the 
lungs,  the  cough  is  ineffectual  in  freeing  the  tubes  of  their  contents. 

Weakness  of  the  inspiratory  act  is  a  powerful  agent  in  preventing  the 
entrance  of  a  sufficient  supply  of  air.  In  ordinary  respiration  the  elastic- 
ity and  contractility  of  the  lung  have  to  be  overcome  by  the  muscles  of  in- 
spiration. If  these  muscles  are  feeble,  as  they  are  in  a  weakly  infant,  the 
obstacle  to  efficient  inflation  of  the  lungs  is  already  great.  If,  however,  in  ad- 
dition, the  respiratory  muscles  are  opposed  by  reflex  contraction  of  the  bron- 
chial muscles,  owing  to  the  irritation  of  the  catarrhal  process,  and  also  by 
mucus  in  the  tubes,  they  may  prove  quite  unequal  to  the  task.  Therefore 
any  cause  which  increases  the  child's  general  weakness  predisposes  to  pul- 
monary collapse.  Thus  vomiting,  diarrhoea,  insanitary  conditions,  im-» 
30 


466  DISEASE   IN   CHILDRElSr. 

proper  feeding,  and  all  the  exhausting  forms  of  illness  may  have  this 
result. 

Besides  the  causes  which  have  been  enumerated,  the  force  of  the  in- 
spiratoiy  act  may  be  weakened  by  mechanical  means.  Interference  with 
the  action  of  the  diaphragm  may  have  important  consequences  in  this  re- 
spect. This  influence  is  especially  seen  in  the  case  of  young  infants.  For 
some  time  after  birth  respiration  is  principally  diaphragmatic  on  account 
of  the  circular  shape  of  the  chest,  which  allows  of  little  lateral  expansion. 
Therefore  any  resistance  to  the  descent  of  the  diaphragm,  such  as  would 
be  produced  by  ascites,  or  great  increase  in  size  of  the  abdominal  organs, 
or  flatulent  distention,  may  so  weaken  the  force  of  the  inspiratory  act  that 
a  very  trifling'  catarrh  determines  wide-spread  and  fatal  collapse  of  the  lung. 

Ajiother  mechanical  means  by  which  the  force  of  the  inspiratory  act 
may  be  interfered  with  is  deficient  rigidity  of  the  chest-wall.  Abnormal 
softening  of  the  ribs  is  a  very  important  agent  in  the  production  of  col- 
lapse, and  the  frequency  and  danger  of  the  lesion  in  rickety  subjects  is 
mainly  owing  to  this  simple  cause.  The  parieties  of  the  chest  in  the  infant 
are  naturally  more  flexible  than  they  are  in  the  adult.  Even  when  the 
ribs  and  their  cartilages  are  perfectly  sound,  considerable  recession  of  the 
lower  ribs  may  be  seen  at  each  inspiration  if  an  impediment  exist  at  any 
part  of  the  air-passages  to  interfere  with  the  ready  entrance  of  air  into  the 
lung.  If  the  ribs  are  softened,  as  in  rickets,  the  same  recession  is  noticed 
although  the  passages  may  be  perfectly  free  ;  for  the  softened  ribs  cannot 
resist  the  pressure  of  the  atmosphere,  and  the  force  of  the  inspired  air  is 
insafficient  by  itself  to  prevent  the  thoracic  parieties,  where  least  supported, 
from  sinking  in.  Consequently  in  this  disease  the  lower  lobes  of  the  lungs 
are  very  insufficiently  filled  with  air.  If  such  a  child  suffer  from  pulmonary 
catarrh,  the  additional  obstacle  to  efficient  inspiration  created  by  the  mucus 
in  the  tubes  may  lead  to  complete  coUapse  of  the  inferior  parts  of  the 
lungs.  On  account  of  the  mechanism  by  which  it  is  produced,  collapse  of 
the  lung  must  always  be  a  secondary  lesion.  It  is  found  as  a  comphcation 
of  various  forms  of  illness.  Diseases  of  which  pulmonary  catarrh  is  a 
common  symptom,  as  whooping-cough  and  measles ;  diseases  which  interfere 
directly  with  the  passage  of  air  through  the  glottis,  as  diphtheria,  laryngitis 
stridulosa,  post-pharyngeal  and  other  abscesses  in  the  neighbourhood  of 
the  larynx  ;  diseases  which  diminish  the  force  of  the  inspiratory  act,  either 
by  mechanical  opposition  as  in  abdominal  tumours  and  rickets,  or  by  im- 
pairing the  muscular  strength  of  the  patient — in  all  these  cases  collapse 
of  the  lung  is  liable  to  be  found. 

llorbid  Anatomy.— The  extent  of  the  collapsed  area  is  in  proportion  to 
the  calibre  of  the  tube  at  the  point  of  obstruction.  According,  therefore, 
as  the  lesion  involves  many  lobules  over  a  considerable  surface,  or  is 
hmited  to  a  few,  the  collapse  is  said  to  be  diffused  or  lobular.  The  airless 
part  of  the  lung  is  shrunken  and  therefore  depressed.  It  is  purple  in 
colour  and  to  the  touch  feels  soft  and  dense.  It  does  not  crepitate.  On 
section  the  surface  is  smooth,  and  blood  or  bloody  serum  exudes  on  press- 
ure.    Around  the  collapsed  portion  the  air-cells  are  emphysematous. 

Lobular  collapse  is  often  situated  at  the  anterior  edges  of  the  lungs, 
but  may  occupy  any  other  parts.  The  diffused  variety  is  most  common  at 
the  posterior  surface,  but  may  be  seen  elsewhere.  It  penetrates  for  a 
variable  distance  into  the  organ,  and  sometimes  an  entire  lobe  or  even  the 
greater  part  of  the  lung  may  be  found  shrunken  and  airless.  After  death, 
if  the  lesion  be  recent,  the  collapsed  tissue  can  be  completely  reinflated 
through  the  bronchus. 


POST-ISTATAL   ATELECTASIS — SYMPTOMS.  467 

Symptoms. — The  symptoms  are  found  to  vary  considerably  in  different 
cases  according  to  tlie  extent  of  the  collapse  and  the  degree  of  strength  of 
the  patient.  In  a  veiy  weakly  infant  rapid  and  extensive  collapse  is  often 
a  cause  of  sudden  death.  In  such  cases  the  preliminary  catarrh  is  not 
necessarily  severe.  Often,  indeed,  it  is  trifling ;  and  the  rapidity  with 
which  death  occurs  gives  rise  to  much  surprise  and  consternation.  The 
impaction  in  a  large  bronchus  of  a  single  plug  of  mucus  may  be  thus  fol- 
lowed in  a  young  and  feeble  subject  by  rapidly  fatal  consequences.  An- 
other common  result  of  the  lesion  is  a  convulsive  seizure  ;  and  sometimes 
the  fits  succeed  one  another  with  great  rapidity,  each  attack  increasing  the 
exhaustion  of  the  patient  and  aggravating  the  pulmonary  mischief  until 
death  ensues.  These  cases  are  not,  however,  always  immediately  fatal. 
In  a  sensitive  child  collajDse  of  comparatively  limited  extent,  if  it  occur 
suddenly,  may  give  rise  to  an  eclamjDtic  seizure  ;  but  this  may  not  be  re- 
peated, and  perhaps  by  judicious  and  energetic  treatment  the  child's  life 
may  be  saved. 

Such  severe  symptoms  are,  however,  exceptional.  In  most  cases  the 
occurrence  of  collapse  is  indicated  by  less  striking  phenomena.  A  weakly 
infant  is  suffering  from  the  ordinary  symptoms  of  bronchial  catarrh.  He 
coughs  more  or  less  loosely  and  his  breathing  is  moderately  hurried,  but 
there  is  nothing  to  excite  apj)rehension.  Suddenly,  however,  a  change  oc- 
curs. The  child  becomes  restless  and  evidently  distressed  ;  his  face  gets 
distinctly  livid,  especially  about  the  eyelids  and  mouth  ;  his  breathing, 
which  had  been  more  laboured  than  natural,  increases  in  rapidity  but  di- 
minishes in  depth  ;  the  cough  ceases  or  is  feeble  and  faint ;  and  the  inter- 
nal temperature  of  the  body  is  found  to  be  below  the  level  of  health. 

The  face  usually  indicates  profound  depression.  The  features  look 
pinched  ;  the  eyes  are  dull  and  hollow  ;  and  the  forehead  is  often  moist 
with  a  cool,  clammy  perspiration.  The  nares  act  in  respiration,  and  the 
breathing  is  very  rapid.  The  number  of  respirations  commonly  reaches 
70  or  80  in  the  minute,  and  the  perversion  of  the  pulse-respiration  ratio  is 
extreme.  In  very  young  infants  the  breathing  is  usually  very  shallow, 
with  little  movement  of  the  chest-walls ;  but  in  infants  eight  or  nine 
months  old,  whose  ribs  are  softened  by  rickets,  the  bases  of  the  chest  sink 
in  to  some  extent  at  each  ins23iratory  movement.  The  child  refuses  to  suck 
and  often  seems  to  have  diificulty  in  swallowing,  so  that  he  can  hardly  be 
persuaded  to  take  milk  from  a  spoon. 

The  physical  signs,  if  any  are  to  be  discovered,  consist  in  slight  dul- 
ness  at  the  posterior  base  of  one  lung,  or  extending  upwards  in  a  narrow 
vertical  strip  at  each  side  of  the  spine.  The  didness  can  often  only  be 
•discovered  by  very  gentle  percussion,  as  a  sharp  blow  with  the  finger  brings 
out  the  resonance  from  healthy  tissue  underlying  the  condensed  layer. 
The  breathing  conducted  from  healthy  tissue  around  is  of  bronchial  quality, 
and  may  be  weak  or  fairly  loud,  according  to  the  strength  of  the  respiratory 
movement.  Vocal  resonance  is  usually  anntdled.  Sometimes  coarse  crep- 
itation is  heard  at  the  confines  of  the  collapsed  area.  These  signs  are  only 
to  be  discovered  when  the  lesion  is  of  the  diffused  variety.  In  lobular  col- 
lapse any  dulness  which  may  be  occasioned  by  the  jDresence  of  the  solidi- 
fied patches  is  neutrahsed  by  the  compensatory  emphysema  set  up  in  their 
neighbourhood. 

When  the  above  symptoms  and  signs  are  noticed,  the  infant's  condition 
is  a  veiy  serious  one  ;  and  unless  prompt  measures  are  taken  to  excite  ex- 
pansion of  the  collapsed  tissue  and  exj^el  the  obstructing  mucus,  death 
must  inevitably  ensue.     The  lividity  increases  or  changes  to  an  ashy  hue. 


468  DISEASE   IN   CHILDEEK". 

the  breathing  grows  more  and  more  shallow,  and  the  child  dies  in  a  state 
of  stupor  from  slow  asphyxia,  or  expu-es  in  a  convulsive  attack. 

In  children  over  a  year  old,  who  are  not  the  subjects  of  rickets,  the 
symptoms  are  usually  less  severe,  and  the  physical  signs  more  nearly  re- 
semble those  which  exist  under  similar  circumstances  in  the  adult.  If  the 
I'ibs  are  softened  from  rickets,  the  impediment  thus  raised  to  efficient  ia- 
spiration  greatly  aggravates  the  effects  of  limitation  of  the  resphatory  sur- 
face, and  in  children  as  old  as  two  or  three  years  the  signs  of  suffering  are 
well  marked.  If,  however,  the  chest-waU  preserves  its  normal  rigidity,  the 
sjTnptoms  are  much  less  characteristic.  The  respiration  may  be  hurried, 
although  this  is  not  always  the  case,  and  the  complexion  may  show  some 
signs  of  deficient  aeration  of  the  blood  ;  but  the  child  is  not  prostrated  by 
the  lesion  ;  he  can  cry  fairly  loudly,  and  his  cough  is  not  suppressed.  On 
examination  of  the  chest,  we  find  dulness  of  variable  extent  on  one  side, 
usually  at  the  base  ;  the  respiration  is  weak  and  harsh  over  the  same  area 
with  absence  of  vocal  resonance,  and  large  moist  Tides  are  heard  about  the 
back.  In  some  cases,  as  when  the  collapsed  area  immediately  surrounds 
a  large  bronchial  tube,  the  rhonchus  may  be  metalhc  and  ringing  as  if 
produced  in  a  cavity. 

If  the  lesion  occupy  the  apex,  the  breathing  is  often  loud  and  bron- 
chial or  blowing,  and  the  dulness  may  be  complete.  In  this  situation  col- 
lapse is  very  likely  to  be  mistaken  for  consolidation  arising  fi'om  other 
causes. 

A  rickety  little  boy,  aged  eighteen  months,  who  had  cut  only  sixteen 
teeth,  was  being  treated  in  the  East  London  Children's  Hospital  for  chronic 
diarrhoea  arising  from  xdceration  of  the  bowels.  The  chest  was  not  de- 
formed and  there  was  no  softening  of  the  ribs.  An  elder  sister  had  died 
in  the  hospital  from  tubercular  peritonitis.  About  a  week  after  the  child's 
admission  he  began  to  cough,  and  in  a  few  days  it  was  noticed  that  the 
percussion-note  at  the  right  supra-spinous  fossa  was  decidedly  high-pitched, 
and  that  the  respiration  there  had  a  faint  bronchial  quality.  There  was  a 
little  coarse  bubbling  about  the  back  on  each  side.  The  temperatm-e  had 
been  generally  about  100°  at  night,  sinking  to  99°  in  the  morning.  The 
pulse  was  96-100  ;  the  respirations  26-30. 

Some  days  afterwards  dulness  at  the  right  apex  behind  had  become 
complete,  and  the  breathiug  was  bronchial  with  a  click  in  the  middle  of 
inspiration.  In  front  the  percussion-note  was  quite  healthy.  The  moist 
rales  over  the  back  persisted.  Temperature  in  the  evening,  99°-100°  ; 
pulse,  80-102  ;  resphations,  20-30.  All  the  time  the  diai-rhoea  continued 
and  the  child  wasted  rapidly.  There  was  more  or  less  general  oedema. 
The  urine  was  albuminous  and  contained  renal  epithehum.  A  few  days 
afterwards  the  child  died  quietly. 

On  examination  of  the  body,  both  lungs  were  found  to  be  emphyse- 
matous with  scattered  patches  of  lobular  collapse.  At  the  posterior  part  of 
the  apex  of  the  right  lung  was  a  patch  of  collapse  which  occupied  the  up- 
per thu-d  of  the  lobe.  Ulcers  were  found  in  the  lower  part  of  the  sygmoid 
fiexure  and  rectum.  The  kidneys  were  congested.  There  was  no  sign  of 
gray  gi-anulations  or  of  caseous  nodules  anywhere  about  the  body. 

This  case  was  mistaken  for  one  of  acute  tuberculosis  with  tuberculous 
ulceration  of  the  bowels.  The  moderate  pyrexia,  the  oedema,  the  albumi- 
nuria, and  the  increasing  signs  of  consolidation  of  the  right  apex  seemed 
to  justify  this  view,  especially  when  considered  in  relation  to  the  history  of 
tubercular  peritonitis  in  the  elder  sister. 

In  some  cases  of  lobular  collapse  where  the  symptoms  are  not  very 


POST-NATAL   ATELECTASIS — SYMPTOMS — DIAGISTOSIS.  469 

severe,  a  considerable  change  all  at  once  is  found  to  occur.  The  tem- 
perature rises,  the  breathing  becomes  laboured,  and  the  lividity  and  signs 
of  distress  increase.  These  symptoms  indicate  the  beginning  of  catarrhal 
pneumonia. 

Sometimes  after  an  attack  of  pleurisy  the  lung  is  left  condensed  and 
airless  and  adherent  to  the  chest-wall,  without  any  mai-ked  contraction  of 
the  side.     This  condition  may  produce  very  puzzling  physical  signs. 

A  little  girl,  aged  fourteen  months,  with  eleven  teeth,  was  said  to  have 
been  a  fine  child  until  the  age  of  ten  months.  At  that  time  she  had  begun  to 
suffer  from  a  cough  which  was  called  whooping-cough  by  the  medical  at- 
tendant. The  child  was  brought  to  the  hospital  for  the  cough,  which  had 
continued  for  four  months,  and  for  general  wasting  of  two  months'  stand- 
ing. On  examination,  although  there  was  no  obvious  contraction  of  the 
right  side  of  the  chest,  the  respiratory  movement  of  that  side  was  seen  to 
be  impaired.  The  lower  intercostal  spaces,  however,  sank  in  fairly  well, 
although  less  deeply  than  on  the  opposite  side.  On  percussion,  complete 
dulness  with  increased  resistance  was  found  over  the  greater  part  of  the 
right  side.  It  extended  over  the  whole  posterior  region,  and  reached  up- 
wards in  the  axilla  to  the  second  rib,  and  in  front  to  the  third.  Towards 
the  spine  behind  the  note  had  a  wooden  quality.  Posteriorly  and  laterally 
the  breath-sounds  were  cavernous  with  abundant  crisp,  clicking  sounds. 
In  front  the  breathing  was  bronchial.  The  resonance  of  the  cough  was 
abnormally  strong. 

On  the  left  side  there  was  no  dulness,  but  the  breathing  was  blowing 
towards  the  apex,  and  some  clicking  rhonchus  was  heard  all  over  the  left 
back.  The  heart's  apex  was  in  the  fourth  interspace  slightly  to  the  outer 
side  of  the  left  nipple  line.  The  edge  of  the  liver  could  be  felt  one  inch 
below  the  ribs. 

The  chest  was  twice  explored  with  a  fine  aspirating  syringe,  but  no  fluid 
could  be  detected.  The  child  eventually  died.  Her  temperature  until 
shortly  before  death  was  normal. 

On  examination  of  the  body  the  right  lung  was  found  to  be  much 
shrunken  and  to  be  universally  attached  by  old  but  readily  separable  ad- 
hesions to  the  chest-wall.  It  was  almost  entirely  non-crepitant,  and  felt 
very  tough  and  firm  in  texture.  Inflation  only  partially  succeeded  in  dilating 
the  condensed  tissue  and  much  force  had  to  be  employed.  On  section  the 
texture  of  this  lung  was  found  to  be  throughout  excessively  tough  and  firm. 
It  was  thought  there  was  some  slight  dilatation  of  the  bronchi.  A  few  nod- 
ular caseous  masses  were  found  scattered  over  the  parenchyma.  The  left 
lung  was  generally  emphysematous,  with  the  exception  of  the  inferior  part  of 
the  lower  lobe,  which  was  collapsed,  but  could  be  reinflated  with  the  blow- 
pipe. This  lung  passed  across  the  middle  line  of  the  chest  and  encroached 
largely  upon  the  right  pleural  cavity.  On  section  it  was  pale  and  contained 
little  blood.  The  kidneys  looked  fatty.  The  heart  and  other  organs 
appeared  to  be  healthy. 

This  case  had  been,  no  doubt,  one  of  pleurisy  in  which  the  effusion  had 
become  absorbed,  leaving  the  lung  in  a  state  of  condensation  and  collapse, 
similar  to  the  gray  induration  described  by  Addison.  The  physical  signs 
were  very  similar  to  those  of  fibroid  indiiration  of  the  lung  ;  indeed,  this 
was  the  opinion  expressed  as  to  the  nature  of  the  case,  in  spite  of  the  tender 
age  of  the  patient. 

Diagnosis. — When  the  collapse  assumes  the  lobular  form,  the  diagnosis 
has  to  be  made  without  the  aid  of  physical  signs.  In  a  well-marked  example, 
however,  the  symptoms  are  so  characteristic  that  an  accurate  opinion  can 


470  DISEASE  I]!^   CHILDHE^^. 

be  formed  without  much  hesitation.  Our  conclusion  is  based  upon  the  fact 
that  in  the  course  of  a  piilmonary  catarrh  signs  are  suddenly  observed  in- 
dicating feebleness  of  inspiratory  power  and  deficient  aeration  of  the  blood. 
Thus,  a  weakly  or  rickety  infant,  who  has  been  noticed  to  cough  for  a  day 
or  two,  all  at  once  begins  to  exhibit  signs  of  restlessness  and  distress.  His 
cough  ceases,  his  cry  is  replaced  by  a  feeble  whim^^er  or  a  mere  distortion 
of  the  featui'es  without  sound  ;  the  eyes  are  hollow  ;  the  complexion  is  livid  ; 
the  nai'es  act ;  the  breathing  is  shallow  and  is  hurried  out  of  proportion  to 
the  pulse  and  the  temperature  is  low. 

if  pulmonary  catarrh  attack  a  feeble  infant,  we  must  always  be  prepared 
for  the  estabhshment  of  collapse,  and  the  sudden  occurrence  of  the  symp- 
toms enumerated,  combined  with  a  low  temperature  and  the  absence  of  all 
physical  signs  connected  with  the  chest,  leaves  us  no  other  explanation  of 
the  child's  condition.  The  only  other  disease  which  would  be  accompanied 
by  a  similar  train  of  symptoms  and  an  equal  perversion  of  the  pulse-respi- 
ration ratio,  without  any  abnormality  of  the  physical  signs,  is  acute  bron- 
cho-pneumonia. In  this  disease,  however,  the  temperature  is  high,  the 
breathing  very  laborious,  and  the  cough  loud  and  hacking.  In  pulmo- 
nary coUapse  the  temperature  is  normal,  or  even  below  the  natural  level  of 
health ;  the  cough  is  feeble  or  suppressed,  and  the  breathing  is  shallow ,. 
for  even  if  there  is  recession  at  the  base  of  the  chest  fi'om  rickets,  there  ia 
no  laboui-ed  movement  of  the  shoulders  or  upper  part  of  the  thoracic  wall. 

A  difficulty  sometimes  arises  from  the  shghtness  of  the  pulmonary 
catarrh.  The  cough  may  be  unnoticed  by  careless  attendants,  and  the 
occurrence  of  such  symptoms  without  being  preceded  by  any  histoiy  of 
cough  may  excite  some  sui-prise.  It  is  necessary,  therefore,  to  remember 
that  atelectasis  may  be  the  consequence  of  a  very  slight  catarrh,  and  that, 
we  are  justified  from  the  sj-mptoms  alone,  and  without  the  presence  of 
physical  signs,  in  drawing  the  conclusion  that  the  child  is  suffering  from 
coUapse  of  the  lung. 

"^^Tien  lobular  coUapse  occurs  in  the  course  of  an  attack  of  mild  bron- 
chitis, the  presence  of  the  lesion  may  be  infen-ed  by  remarking  that  the 
symptoms  of  prostration  and  deficient  oxydation  of  the  blood  are  exagger- 
ated out  of  all  proportion  to  the  physical  signs.  If  the  bronchitis  be  severe, 
we  may  conclude  that  atelectasis  is  present  if  the  breathing  becomes  sud- 
denly shallow  and  rapid ;  if  the  cough  and  cry  become  suppressed  ;  while 
the  Hvidity  and  general  distress  are  still  further  aggravated,  and  the  in- 
ternal temperature  of  the  body  falls  below  the  level  of  health. 

In  cases  of  difiused  atelectasis  an  examination  of  the  chest  reveals- 
dulness,  bronchial  breathing,  and  a  sub-crepitant  rhonchus.  The  disease 
may  then  be  mistaken  for  croupous  pneumonia  or  pleurisy.  In  a  young 
infant,  howevei',  httle  hesitation  is  occasioned,  for  the  symptoms  induced 
by  atelectasis  are  very  different  from  those  resulting  from  either  of  the 
diseases  which  have  l^een  mentioned.  It  is  principally  in  cases  where  the 
lesion  occui's  after  the  end  of  the  first  year  that  any  iDerplexity  is  ex- 
perienced. .  At  this  age  the  general  symptoms  are  iisually  less  severe  and 
the  child's  weakness  much  less  pronounced.  Still,  the  history  of  the  illness- 
is  veiy  different  in  collapse  from  that  of  a  case  of  inflammation  either  of 
the  lung  or  the  pleui-a.  Moreover,  in  pneumonia  the  high  temperatiu'e  is 
a  distinguishing  mark  of  great  value  ;  and  tubular  breathing,  with  a  fine, 
puff)'  crepitation  noticed  at  the  borders  of  the  dull  area,  are  signs  wliich  are 
not  heard  in  collapse  of  the  lung.  From  a  localised  pleiu'isy  the  lesion  is 
not  always  so  easily  distinguished.  Collapse  of  a  mere  layer  of  tissue  on 
the  surface  of  the  lung  gives  rise  to  onl}'  moderate  dulness  quite  unhke 


POST-ITATAL   ATELECTASIS— PEOGKOSIS— TREATMENT.        471 

the  dead,  toneless  note  over  even  a  thin  stratum  of  fluid.  If,  however,  an 
entire  pulmonary  lobe  be  collapsed,  the  dulness  may  be  very  marked  and 
the  resistance  notably  increased,  although  perhaps  to  a  less  extent  than  is 
found  in  cases  of  pleurisy  ;  still,  the  difference  is  one  only  of  degree.  Ta 
add  to  the  resemblance,  the  breathing  in  either  case  may  be  w^eak  and 
bronchial  without  rhonchus  or  other  adventitious  sound.  If,  however,  the 
vocal  resonance  be  oegophonic,  the  sign  is  characteristic  of  j)leurisy  and 
is  never  found  over  merely  collapsed  lung-tissue.  In  most  cases  the 
symptoms  alone  in  the  two  diseases  are  sufficiently  different  to  warrant  a 
diagnosis.  In  atelectasis  the  distress  is  greater,  and  the  signs  of  lividity 
are  more  noticeable  than  in  the  case  of  pleurisy  of  equal  extent ;  for  in 
the  latter  disease,  unless  a  great  accumulation  of  fluid  occur,  or  the  pain 
be  severe,  the  chUd,  as  a  rule,  appears  little  inconvenienced  by  his  illness. 

When  the  collapse  occupies  the  apex  of  the  lung,  as  in  the  case  narrated 
above,  it  is  often  distinguished  with  difficulty  from  an  ordinary  caseous 
consolidation,  especially  if  any  complication  be  present,  as  in  that  case,  to 
raise  the  temperature  of  the  body  above  the  natural  level.  Still,  one  dis- 
tinguishing mark  which  was  present  in  the  case  referred  to  might  suggest 
simple  condensation  of  tissue,  viz.,  the  limitation  of  the  dulness  to  one 
aspect  of  the  chest.  Complete  dulness  arising  from  consolidation  would 
be  certainly  accompanied  by  a  corresponding  alteration  of  the  percussion- 
note  on  and  above  the  clavicle  as  well  as  at  the  supra-spinous  fossa. 

Prognosis. — Post-natal  atelectasis  is  always  a  grave  lesion,  especially  in 
weakly  children.  Indeed,  if  the  collapse  occur  in  the  course  of  a  severe 
attack  of  bronchitis,  and  the  patient  be  a  feeble  or  rickety  infant  under 
the  age  of  twelve  months,  death  may  be  looked  upon  as  inevitable.  Even 
when  the  preliminary  catarrh  is  less  severe,  the  life  of  the  child  is  placed 
in  great  danger  ;  and  if  the  collapse  be  extensive,  or  the  softening  of  the 
ribs  extreme,  treatment  must  be  very  prompt  and  energetic  indeed  to  afford 
any  prospect  of  success.  The  occurrence  of  convulsions  greatly  increases 
the  danger  of  the  case  ;  and  marked  apathy  and  torpor,  persistent  increase 
of  Uvidity,  great  shallowness  of  breathing,  and  inabihty  to  swallow  are  all 
symptoms  of  unfavourable  import.  On  the  contraiy,  if  the  face  become 
clearer  and  the  breathing  deeper,  and  especially  if  the  child  begin  to  suck 
his  fingers,  to  take  his  bottle  readily,  or  to  show  any  interest  in  what  passes 
around  him,  we  may  have  hopes  of  his  recovery. 

Treatment. — Re-inflation  of  the  collapsed  air-cells  in  cases  of  atelec- 
tasis can  only  be  effected  by  measures  which  increase  the  vigour  of  the  in- 
spiratory movement.  To  attain  this  object  we  must  make  use  of  energetic 
stimulation  both  internally  and  externally.  The  child  should  be  placed 
as  quickly  as  possible  in  a  hot  mustard-bath  of  the  strength  of  one  ounce 
of  mustard,  to  each  gaUon  of  hot  water.  In  this  bath  he  should  be  al- 
lowed to  remain  until  the  arms  of  the  person  supporting  him  begin  to 
prick  and  tingle  uncomfortably.  After  being  removed  and  dried,  the 
chest  should  be  wrapped  loosely  in  cotton  wool,  and  the  child  be  laid 
quietly  in  his  cot  with  head  and  shoulders  raised.  The  temperature  of 
the  room  should  be  between  70°  and  15°.  If  any  signs  are  observed  of 
accumulation  of  phlegm  in  the  tubes,  an  emetic  is  useful ;  and  a  quarter 
or  half  a  grain  of  sulphate  of  copper  (according  to  the  age  of  the  child) 
may  be  given  in  a  teaspoonful  of  water  every  ten  minutes  until  vomiting  is 
produced.  The  emetic  is  also  valuable  in  forcing  the  child  to  take  a  deep 
breath.  Mechanical  means  of  increasing  the  depth  of  the  inspirations 
form  an  important  part  of  the  treatment.  The  infant  should  not  be  al- 
lowed to  sleep  too  long  at  one  time.     Drowsiness  is  one  of  the  commonest 


472  DISEASE  IF   CHILDEElSr. 

symptoms  of  tMs  lesion  ;  but  a  careful  eye  should  be  kept  upon  the  pa- 
tient during  his  sleep,  and  if  signs  of  increasing  hvidity  are  noticed,  he 
must  be  taken  up  and  put  into  a  mustard-bath,  or  made  to  cry  by  frictions 
to  the  soles  of  his  feet  or  by  the  apphcation  of  a  strong  stimulating  lini- 
ment to  the  chest- wall.  The  hnimentum  ammonite  of  the  British  Phar- 
macopoeia, diluted,  if  necessary,  with  an  equal  quantity  of  ohve-oil,  is  very 
useful  for  this  purpose. 

If  the  child  can  suck,  he  should  take  white  wine  whey  with  cream  from 
a  bottle.  In  many  cases,  however,  on  account  of  his  inabihty  to  draw  up 
the  fluid  through  the  tube,  it  is  necessary  to  feed  him  with  the  syringe. 
In  addition,  or  as  a  variety,  the  child  may  be  fed  with  milk  and  barley- 
water  with  MeUin's  food,  and  five  or  ten  drops  of  pale  brandy  must  be 
given  at  regular  intervals.  In  the  case  of  a  weakly  infant,  when  the  symp- 
toms of  prostration  are  great,  the  stimulant  will  be  requii-ed  every  half 
hoiu-  until  the  child  revives.  Older  children  may  take  milk,  strong  beef- 
tea,  and  the  brandy-and-egg  mixtui-e. 

The  above  measui-es  must  be  put  in  force  directly  any  signs  are  dis- 
covered indicating  the  occurrence  of  collapse.  The  earlier  special  treat- 
ment is  begun,  the  more  likely  is  it  to  be  successful.  It  is  of  the  utmost 
importance  that  the  child  be  not  allowed  to  sleep  himself  to  death,  as  he 
will  probably  do  if  left  alone.  He  must  be  roused  at  intervals  and  made 
to  inspii-e  ;  and  our  efforts  must  be  continued  perseveringly  until  signs  are 
noted  of  returning  vigour  or  of  improved  aeration  of  the  blood.  Even 
then  he  must  be  carefuUy  watched  that  he  may  not  relapse,  and  stimu- 
lation must  be  continued  until  all  danger  has  passed. 

Prugs  are  not  of  much  value  in  this  lesion.  Opium  is  to  be  carefully 
avoided.  Diffusible  stimulants  may,  however,  be  given  if  thought  advis- 
able. The  best  of  these  is  quinine  dissolved  in  sal  volatile  in  the  propor- 
tion of  one  grain  to  the  di'achm.  Three  or  four  drops  of  this  solution 
may  be  given  occasionally  in  a  spoonful  of  the  food. 


CHAPTER  YIII. 

FIBROID  INDURATION  OF  THE  LUNG. 

PiBEorD  indiiration  of  the  lung  (cirrliosis  of  the  lung,  interstitial  pneumonia) 
is  not  very  uncommon  in  children,  and  is  often  mistaken  for  phthisis.  The 
complaint  gives  rise  to  a  chronic  derangement  of  health  which  is  subject 
to  marked  variations  according  to  the  season  of  the  year.  In  cold  and 
changeable  weather  the  patient  suffers  greatly  from  attacks  of  bronchitis 
and  catarrhal  pneumonia.  Consequently,  at  these  times  he  is  apt  to  be 
feverish  and  grow  pale  and  thin,  even  if  his  life  be  not  put  in  actual  peril. 
In  warmer  and  more  settled  weather  he  usually  greatly  improves  and  gains 
considerably  both  in  flesh  and  strength.  Cases  of  very  chi'onic  "consump- 
tion," in  which  the  patient  is  constantly  ill  and  failing  during  the  winter, 
but  revives  and  regains  flesh  during  the  summer  months,  are  often  exam- 
ples of  this  form  of  pulmonary  disease.  Cirrhosis  of  the  lung  rarely  at- 
tacks infants.  It  is  usually  found  in  children  of  five  years  old  and  up- 
wards. 

Pathology. — Fibroid  induration  is  always  a  secondary  complaint,  and 
usually  owes  its  origin  to  an  attack  of  inflammation  of  the  lung.  Both 
croupous  and  catarrhal  pneumonia  tend  to  promote  a  multiplication  of  the 
connective  tissue  elements  ;  but  in  children  the  fibroid  increase  is  commonly 
due  to  the  lobular  form,  especially  to  the  subacute  variety  which  is  apt 
to  follow  attacks  of  measles  and  whooping-cough.  Catarrhal  pneumonia 
is  always  accompanied  by  dilatation  of  the  bronchi,  and  this  condition  of 
the  air-tubes  favours  the  catarrhal  process.  It  hinders  the  escape  of  secre- 
tion and  so  maintains  a  state  of  continual  irritation  of  the  air-tubes  and 
their  terminal  alveoli.  As  a  result,  the  persistence  of  the  pulmonary  in- 
flammation tends  to  promote  a  fibroid  thickening  of  the  walls  of  the  bronchi 
and  air-cells  ;  the  dilatation  of  the  tubes  becomes  a  permanent  lesion,  and 
this,  again,  helps  in  its  turn  to  perpetuate  the  irritation. 

Croupous  pneumonia  is  less  often  than  the  preceding  a  cause  of  cirrho- 
sis ;  but  sometimes,  if  the  disease  is  protracted,  thickening  and  indura- 
tion may  occur  in  the  walls  of  the  alveoli,  and  the  indurating  process  may 
continue  after  the  original  disease  is  at  an  end.  Weber  has  reported  the 
cases  of  three  children  in  whom  the  disease  had  this  origin,  for  he  had 
himself  treated  the  patients  for  the  primary  attack  of  pneumonia. 

Sometimes,  although  rarely  in  young  subjects,  inflammation  of  the 
pleura  may  lead  to  the  fibroid  overgrowth.  It  is  in  cases  where  the  lung 
has  been  subjected  to  long-continued  compression  that  this  consequence 
is  most  likely  to  occur.  The  thickening  in  this  form  is  limited  at  first  to 
the  superficial  interlobular  septa  ;  but  the  process  may  afterwards  pene- 
trate more  deeply  and  be  accompanied  by  dilatation  of  the  bronchi. 

Induration  of  the  two  lungs  as  a  consequence  of  the  inhalation  of  gi'it 
in  the  course  of  industrial  labour  is  not  found  in  children.  Young  persons 
under  twelve  years  of  age  are  not  exposed  to  this  source  of  disease  ;  and 


474  DISEASE  IX  childee:^". 

even  in  adults  ■u-laose  emploTment  obliges  them  to  breathe  continually  an 
air  filled  with  irritating  particles,  disease  of  the  lung  thus  induced  is  in- 
Yariably  chronic,  and  only  becomes  developed  after  an  exposure  extend- 
ing over  many  years. 

Morbid  Anatomy. — On  examination  of  a  lung,  the  seat  of  fibroid  indiu-a- 
tion,  a  great  development  is  noticed  of  fibro-nucleated  tissue  in  the  walls 
of  the  alveoli,  the  interlobular  connective  tissue,  and  the  bronchial  tubes. 
As  this  increases  it  involves  aU  the  connective  tissue  of  the  lung.  The  or- 
gan becomes  excessively  dense  and  shrunken.  Its  substance  is  fii'm  and 
tough,  and  a  section  shows  a  smooth  or  faintly  granular  sui-face,  ii'on-gray 
or  grayish-red  in  colour,  intersected  in  all  dii'ectious  by  white  fibrous 
bands.  Dotted  over  it  are  Avhite  rings  of  various  sizes,  which  are  the  di- 
vided walls  of  thickened  and  dilated  tubes. 

The  fibroid  material  is  not  spread  evenly  over  the  parenchyma,  but 
often  surrounds  islets  of  more  healthy  tissue,  which  are  thus  separated 
from  one  another  by  the  dense  fibrous  bands.  Sometimes  in  the  neigh- 
bourhood of  the  fibroid  parts  the  uninvaded  tissue  may  be  emphysematous. 
Small  cavities  containing  cheesy  matter  or  thick  pui-ulent  fluid  ai-e  seen 
here  and  there  in  the  dense  tissue.  Some  of  these  are  dilatations  of  the 
bronchi  ;  others  are  the  result  of  ulceration  which  has  spread  fi'om  the 
enlarged  tubes.  Sometimes,  as  in  the  case  of  a  child  five  years  old  who 
was  under  my  care  in  the  East  London  Childi-en"s  Hospital,  large  exjDanded 
channels  are  found  radiating  from  the  root  of  the  lung  and  ending  abruptly, 
like  the  fingers  of  a  glove,  at  the  snrface  of  the  organ  immediately  under- 
neath the  pleura. 

When  the  disease  follows  upon  an  attack  of  croupous  pneumonia  the 
change  principally  involves  the  alveoh.  The  walls  of  the  air-cells  become 
greatly  thickened,  and  in  some  cases,  at  least,  as  in  an  instance  reported  by 
Dr.  Sidney  Coupland,  the  exudation  products  filling  the  alveoh  become  or- 
ganised into  a  fibrillated  and  at  first  vasculai'ised  mesh- work.  By  this 
means  the  alveoh  are  either  compressed  or  filled  up,  and  in  either  case  ef- 
faced ;  and  as  the  tissue  shi'inks,  the  new  vessels  which  had  been  devel- 
oped in  the  growing  tissue  become  obhterated. 

If  the  cirrhosis  originate  in  a  broncho-pneumonia  the  alveolar  walls  are 
thickened  as  in  the  former  case ;  but  in  addition  there  is  great  develop- 
ment of  fibroid  tissue  in  the  walls  of  the  bronchi  and  in  the  connective 
tissue  between  tJLie  lobules.  In  these  cases  whitish  bands  are  seen  radia- 
ting from  the  thickened  walls  of  the  air-tubes. 

^Tien  the  morbid  process  starts  fi-om  the  pleura,  dense  fibrous  bands 
pass  inwards  from  the  siu'face.  The  pleura  itself  is  greatly  thickened,  and 
the  lung-tissue  underlying  it  may  be  converted  after  a  time  into  a  dense 
fibrous  substance.  At  first,  however,  the  fibroid  degeneration  is  more 
partial  than  in  cases  where  the  disease  is  the  consequence  of  pneumonia. 

Microscopic  examination  discovers  closely  packed  wavy  fibres  in  the 
denser  portions,  or  even  a  homogeneous  or  faintly  fibiiUated  material  with 
a  few  small  round  or  fusiform  cells. 

The  alveoh,  where  not  completely  compressed  and  effaced,  are  either 
empty  or  are  filled  with  nucleated  and  epithehal  cells,  granular  corpuscles^ 
and  granules. 

The  bronchi  are  either  obhterated  or  are  greatly  thickened  and  dilated, 
especially  in  parts  where  the  disease  is  most  advanced.  The  tubes  are  in 
some  cases  regularly  eiilarged,  but  sometimes  more  local  dilatations  are 
seen  forming  cavities  of  various  sizes.  The  lining  mucus  membrane  may 
be  ulcerated,  and  in  very  advanced  cases  iilcerative  destruction  of  tissue 


FIBROID   INDURATION   OF   THE  LUNG — SYMPTOMS.  475 

may  have  penetrated  from  these  spots  into  the  hmg.  This  form  of  the 
disease  has  been  called  "fibroid  phthisis"  by  Sir  Andrew  Clark. 

Fibroid  induration  is  usually  limited  to  one  lung,  the  other  being 
healthy  or  emphysematous.  It  may  occupy  any  part  of  the  organ  but  more 
commonly  affects  the  base  than  the  apex. 

In  addition  to  the  mischief  in  the  lung,  disease  is  often  found  in  other 
parts.  The  liver,  spleen,  and  sometimes  the  kidneys  may  be  the  seat  of 
amyloid  degeneration.  In  some  cases  the  liver  has  been  found  to  be  cir- 
rhotic and  the  kidneys  to  be  granular. 

Symjjtoms. — In  the  early  stage  of  the  disease  the  development  of  fibroid 
tissue  in  the  lung  is  accompanied  by  no  special  symptoms.  The  process 
most  commonly  begins  at  the  end  of  an  attack  of  catarrhal  pneumonia.  In 
some  children  we  find  a  peculiar  tendency  to  recurring  attacks  of  this  form 
of  pneumonia  of  very  unusual  duration.  Between  the  attacks  the  child 
seems  almost  well,  and  an  examination  of  the  back  detects  merely  a  slight 
impairment  of  resonance  on  one  side  (best  detected  by  "  broad  percus- 
sion "  upon  three  fingers  at  once),  with  perceptible  increase  in  the  resist- 
ance. The  respiratory  sounds,  however,  are  normal.  When  an  attack  of 
catarrhal  pneumonia  comes  on,  the  symptoms  and  signs  are  those  peculiar 
to  that  form  of  inflammation  of  the  lung.  If  death  occur  after  a  prolonged 
attack  of  broncho-pneumonia,  we  may  find  one  of  the  lungs  small,  shrunken, 
and  particularly  firm  to  the  touch  ;  and  notice  on  section  that  the  inter- 
lobular septa  and  walls  of  the  bronchioles  are  much  thickened,  especially 
at  the  base  of  the  organ,  and  that  the  bronchi  are  dilated.  Such  a  con- 
dition constitutes  an  early  stag'e  of  the  fibroid  change  in  the  lung.  The 
incipient  fibrosis,  beyond  conferring  a  certain  high-pitched  quaHty  upon  the 
percussion  note — and  this  sign  is  but  an  indefinite  one — gives  rise  to  no 
symptoms.  Nutrition  is  not  interfered  with,  the  appetite  is  good,  and  the 
temperature  is  normal.  Pyrexia,  cough,  loss  of  appetite,  and  impairment 
of  nutrition  only  occur  as  a  result  of  an  intercurrent  inflammatory  attack  ; 
and  at  these  times  only  are  any  pronounced  physical  signs  to  be  detected 
on  examination  of  the  chest.  Dulness  is  then  marked  and  extensive  ;  the 
breathing  becomes  blowing  or  tubular  ;  and  coarse  bubbling  or  sub-crepi- 
tant  rhonchus — more  or  less  metallic  and  ringing  according  to  the  degree 
of  acute  dilatation  of  the  tubes— is  to  be  heard  with  the  stethoscope. 
After  each  of  these  attacks  the  lung  is  left  in  a  distinctly  worse  condition 
than  before.  The  fibroid  overgrowth  increases  in  the  lung  ;  the  bronchi 
get  to  be  permanently  dilated  ;  and  the  lining  membrane  of  the  air-tubes 
becomes  the  seat  of  more  or  less  persistent  catarrh. 

Even  when  the  fibroid  overgrowth  has  increased  to  such  a  degree  as 
seriously  to  impair  the  usefulness  of  the  lung  as  a  respiratory  organ,  the 
influence  of  the  disease  upon  general  nutrition  may  be  comparatively  slight 
so  long  as  the  chest  is  fi'ee  from  intercurrent  attacks  of  bronchitis  or  ca- 
tarrhal pneumonia.  Special  symptoms  arising  from  contraction  of  the 
lung  and  consequent  obstruction  to  the  pulmonary  and  systemic  circulation 
are  to  be  noticed  ;  but  if  no  secondary  disease  of  organs  has  been  induced 
by  his  illness,  the  child  is  often  fairly  stout  and  strong.  Therefore,  in  warm 
and  settled  weather,  which  brings  with  it  freedom  from  catarrh,  his  health 
may  afford  little  subject  for  complaint ;  but  in  changeable  seasons,  and  es- 
pecially during  the  winter  months,  he  wastes  rapidly  and  exhibits  all  the 
symptoms  of  "  consumption." 

When  the  disease  occurs  as  a  sequel  to  an  attack  of  pleurisy,  the  early 
symptoms  vary  according  as  to  whether  the  pleuritic  effusion  and  conse- 
quent compression  of  the  lung  have  been  moderate  or  excessive.     In  the 


476    '  DISEASE   IN   CHILD RElSr. 

first  case,  unless  a  local  catarrh  be  present  the  general  symptoms  may  be 
insignificant ;  and  a  physical  examination  may  only  detect  dulness  at  the 
extreme  base  behind,  with  very  weak  bronchial  breathing  and  some  coarse 
bubbles  with  respiration.  The  child  maybe  subject  to  paroxysmal  cough, 
but  need  not  for  a  long  time  necessarily  sufier  in  his  nutrition  through  the 
condition  of  his  lung.  If,  however,  effusion  have  been  copious,  and  the 
Iwng  be  bound  down  by  thick  bands  of  lymph,  the  symptoms  and  physical 
signs  are  those  of  pleurisy  with  retraction,  combined  with  j)aroxysmal 
cough,  profuse  expectoration  of  offensive  muco-pui-ulent  sputa,  and  the 
other  phenomena  which  attend  a  case  of  pronounced  cirrhosis  of  the  lung. 

In  the  fuUy  estabhshed  disease  we  find  the  following  signs  : 

On  account  of  the  diminution  in  size  of  the  affected  lung,  the  chest-waH 
con-esponding  to  the  shrunken  organ  is  retracted.  The  ribs  are  flattened 
over  the  seat  of  disease,  and  the  respiratory  movement  is  impaired  or  sup- 
pressed. If  the  lung  is  much  reduced  in  size,  the  shoulder,  the  nijDple, 
and  the  inferior  angle  of  the  scapula  are  lowered,  the  ribs  are  approxi- 
mated, and  the  circumference  of  the  chest  on  that  side  is  diminished  to 
the  measuring  tape.  An  outline  of  the  chest  dra"v\Ti  from  the  cyrtometer 
shows  this  diiference  between  the  two  sides  veiy  clearly.  In  addition  a 
certain  displacement  of  soft  parts  in  the  neighbourhood  is  to  be  noted. 
The  mediastinum  is  drawn  towards  the  affected  side,  and  the  023posite  lung 
is  found  on  percussion  to  project  across  the  middle  line  of  the  chest.  The 
heart  is  also  displaced,  unless  adhesions  between  the  pericardium  and  ad- 
joining pleura  retain  it  in  its  normal  position.  If  the  upper  part  of  the 
left  lung  be  the  seat  of  disease,  the  heart  is  drawn  upwards.  If  the  right 
lung  be  affected,  the  heart  is  pulled  towards  the  right  side,  and  in  extreme 
cases  may  be  felt  beating  to  the  right  of  the  sternum.  Vocal  vibration  is 
sometimes  plainly  perceptible  over  the  indurated  organ,  although  it  is  ab- 
sent from  the  soiind  side.  In  other  cases  no  fremitus  may  be  perceived 
over  the  affected  half  of  the  chest  when  the  child  speaks,  although  it  can 
be  felt  over  the  healthy  lung.  The  percussion-note  is  of  wooden  or  tubular 
quahty,  and  there  is  usually  marked  resistance  of  the  chest-wall.  This  in- 
crease of  resistance  is  especially  noticeable  when  the  diseased  lung  is  the 
seat  of  an  intercurrent  attack  of  broncho-pneumonia  ;  and  the  percussion 
note  at  this  time  may  be  as  completely  dull  and  toneless  as  in  cases  of 
pleuritic  effusion.  The  breath-sound  is  found  to  vary  according  to  the 
amount  of  secretion  retained  in  the  tubes  at  the  time  of  examination.  If 
the  dilated  tubes  are  full  of  muco-pus,  the  breath-sound  is  weak  and  bron- 
chial, with  httle  rhonchus  ;  and  resonance  of  the  voice  when  the  child 
speaks  is  faint  or  suppressed.  If  the  air-passages  are  comparatively  empty, 
the  respiration  is  loud  and  blowing,  often  intensely  cavernous,  or  even 
amphoric,  with  metallic  echo  ;  and  large,  crisjD,  metallic  bubbles,  with  dry, 
creaking  sounds,  are  heard  with  both  inspiration  and  expu^ation.  These 
signs  are  in  most  cases  limited  to  one-half  of  the  chest. 

The  symptoms  noted  in  a  case  of  j)ronounced  cuThosis  are  in  part  due 
to  the  condition  of  the  lung  itself ;  but  in  part  they  are  the  consequence 
of  the  obstructed  pulmonary  cii'culation. 

The  cough  is  a  very  characteristic  symptom.  Owing  to  retention  of 
secretion  in  the  dilated  tubes,  and  to  loss  of  elasticity  in  their  indurated 
walls,  cough  is  severe  and  spasmodic.  It  occurs  at  comparatively  rare  in- 
tervals, and  consists  in  a  rapid  succession  of  loose-sounding  hacks  which 
often  continue  for  many  minutes.  The  child's  face  becomes  congested 
and  his  eyelids  suffused,  and  his  whole  body  often  shakes  with  the  vio- 
lence of  the  paroxysm.     After  lasting  a  variable  time  the  cough  ends  in 


FIBROID   INDUEATIOX   OF   THE   LUjS'G — SYMPTOMS.  477 

spasmodic  contractions  of  the  diaphragm,  and  enormous  quantities  of 
offensive  purulent  matter  are  retched  or  expectorated.  The  unpleasant 
smell  of  the  morbid  secretion  is  due  partly  tb  its  retention  and  consequent 
putrefaction  in  the  dilated  tubes,  and  parti}'  to  the  presence  in  it  of  gan- 
grenous shreds  of  mucous  membrane.  The  same  causes  communicate  a 
fetor  to  the  child's  breath,  which  can  be  perceived  at  a  considerable  dis- 
tance from  his  cot.  Sometimes  the  expectorated  matters  are  tinged  with 
blood  ;  but  haemoptysis  from  this  cause  is  not  common  in  the  child. 
Epistaxis  may,  however,  occur,  and  the  blood  from  the  nose  may  be  swal- 
lowed and  retched  uj)  again  at  the  end  of  a  cough,  so  as  to  appear  as  if 
brought  up  from  the  lungs. 

The  respirations  are  usually  from  30  to  35  in  the  minute.  If  broncho- 
pneumonia be  superadded,  the  breathing  becomes  much  more  hurried,  and 
the  pulse-respiration  ratio  is  perverted, 

The  ajDpetite  is  often  good,  and  although  the  child  is  pale  as  a  rule,  his 
nutrition,  as  has  been  said,  unless  interfered  with  by  an  intercurrent  in- 
flammatory attack,  may  be  fairly  satisfactory.  During  the  attacks  of  ca- 
tarrhal pneumonia,  however,  he  wastes  rapidly  ;  and  if  the  disease  has 
produced  marked  contraction  of  the  side,  the  child  is  usually  greatly 
emaciated. 

Pyrexia  is  not  a  symptom  of  the  uncomphcated  disease.  When  pres- 
ent, it  usually  indicates  the  occurrence  of  bronchitis  or  pneumonia,  and 
is  then  102°  or  103°,  or  even  higher.  A  more  moderate  pyrexia  may  be 
the  consequence  of  ulceration  of  the  bronchial  tubes.  In  these  cases  a 
microscopical  examination  of  the  sputum  will  discover  the  presence  of 
fibres  of  elastic  tissue. 

In  addition  to  the  above  symptoms  others  are  present  which  are  the 
consequence  of  interference  with  the  pulmonary  circulation.  The  right 
side  of  the  heart  becomes  hypertrophied,  and  the  systemic  venous  system 
is  fuller  than  natural,  so  that  the  veins  of  the  neck  and  chest,  and  often  of 
the  limbs,  are  abnormally  prominent.  The  fingers  are  clubbed,  and  in 
advanced  cases  there  may  be  a  congested,  turgid  appearance  of  the  face. 

Amyloid  disease  of  the  liver,  spleen,  and  kidneys  is  commonly  present 
in  advanced  cases.  If  this  be  marked,  there  may  be  gi'eat  anaemia  and 
general  dropsy. 

Although  in  most  cases  fibroid  induration  of  the  lung  is  accompanied 
by  marked  contraction  of  the  side,  this  symptom  is  not  always  present. 
In  one  of  the  most  pronounced  examples  of  the  disease  which  has  come 
under  mj  notice — a  child  of  five  years  old — the  chest  was  well-shaped,  and 
the  affected  half,  although  slightly  flattened  posteriorly  and  at  the  junction 
of  the  lateral  and  anterior  thirds,  was  little  inferior  to  the  healthy  side  in 
actual  measurement.  In  this  case  dissection  of  the  body  showed  that 
the  shrinking  and  condensation  of  the  lung  tissue  was  compensated  for  by 
enormous  dilatation  of  the  air-tubes,  so  that  the  space  occupied  by  the  or- 
gan in  the  chest  cavity  was  little  diminished.  Even  if  the  lung  be  con- 
densed so  as  to  reduce  its  volume  much  below  the  standard  of  health, 
marked  contraction  of  the  chest  may  be  prevented  by  the  drawing  into 
the  affected  side  of  movable  organs  in  the  neighboui'hood.  Thus,  in  a  boy 
— aged  eleven  years — in  whom  the  shrunken  right  lung  was  reduced  to  a 
mere  mass  of  gristle,  the  enlai'ged  amyloid  liver  was  drawn  upwards  so 
that  its  upper  border  was  at  the  level  of  the  third  rib.  This  displacement 
prevented  the  chest  from  faUing  in,  and  the  contraction  of  the  side  was 
limited  to  a  Httle  flattening  under  the  clavicle. 

In  cases  where  ulcerative  destruction  of  lung  ensues  (fibroid  phthisis) 


478  DISEASE   IX   CHILDREN. 

there  is  great  interference  •with  nutrition.  The  temperature  is  elevated, 
there  is  often  hectic,  and  diarrhoea  may  occur  with  tdceration  of  the 
"bowels.  The  symptoms  are  those  common  to  the  third  stage  of  consump- 
tion, and  the  physical  signs  are  such  as  have  been  described  as  accompany- 
ing confirmed  j^ulmonary  cm'hosis.  In  these  cases  the  desti-uctive  process 
is  soon  followed  by  signs  of  deposit  at  the  apex  of  the  opposite  lung. 

Fibroid  induration  does  not  always  go  en  to  fibroid  phthisis.  In 
children,  at  least,  this  is  an  exceptional  mode  of  ending  of  the  disease. 
As  a  rule  the  child  succumbs  to  one  of  the  intercuiTent  attacks  of  broncho- 
pneumonia, or  falls  a  rictim  to  a  secondary  acute  tuberculosis. 

Diagnosis. — In  the  early  stage  of  fibroid  indiu-ation  of  the  lung  a  certain 
diagnosis  is  impossible.  We  may  suspect  that  the  process  is  proceeding  if 
a  child  be  subject  to  repeated  attacks  of  inflammation  of  the  lung,  and  if 
after  an  unusually  prolonged  attack  of  catarrhal  pneumonia  the  percussion- 
note  remains  high  j)itched,  and  the  indications  of  dilatation  of  the  bronchi 
are  slow  to  subside  ;  but  no  positive  oiDinion  can  be  hazarded  upon  such 
insufficient  data. 

The  diagnosis  of  the  confirmed  disease  rests  upon  the  signs  of  shrink- 
ing and  condensation  of  lung  tissue  combined  -with  evidence  of  dilatation  of 
the  bronchi.  There  is  great  retraction  of  the  affected  side,  indicated  by 
faUing  in  of  the  chest--wall,  lowering  of  the  shoulder,  nipjole,  and  inferior 
angle  of  the  scapula,  with  cui'ving  of  the  sjDine — the  concavity  being 
towards  the  affected  side.  Neighbouring  organs  are  displaced.  If  the 
right  lung  be  diseased,  the  hver  is  drawn  upwards,  the  heart  is  felt  beat- 
ing to  the  right  of  its  normal  joosition,  and  the  resonance  of  the  left  lung 
passes  across  the  middle  hne  of  the  chest.  If  the  left  lung  be  contracted, 
the  heart  is  drawn  upwards  and  the  right  lung  encroaches  upon  the  left 
pleural  cavity. 

On  examination  of  the  chest  the  percussion-note  is  wooden  or  tubular, 
with  marked  resistance,  the  breath-sound  is  weak  or  bronchial  if  the  tubes 
contain  much  secretion,  while  after  cough  and  expectoration  loud  blowing 
or  cavernous  breathmg  is  heard,  with  large  metallic  bubbling  rhonchus, 
and  intense  bronchophonic  resonance  of  the  voice.  We  find,  also,  indica- 
tions of  interference  with  the  pulmonary  chculation.  The  right  ventricle 
is  hypertrophied  ;  the  veins  of  the  neck,  chest,  and  arms  are  fuller  than 
natural,  and  the  fingers  are  clubbed. 

The  violent  ^oaroxysmal  cough  ending  in  retching,  and  the  discharge  of 
a  large  quantity  of  offensive  jDurulent  mucus  is  veiy  characteristic  ;  and 
this  s}TQptom,  combined  with  the  sudden  change  in  the  physical  signs 
which  is  noticed  at  once  when  the  dilated  tubes  have  been  relieved  of  their 
contents,  is  a  strong  argument  in  favour  of  fibroid  indui-ation. 

Pleurisy,  with  retraction  of  the  side,  presents  j^hysical  signs  veiy  similar 
to  the  above.  But  in  this  case,  although  the  breathing  in  the  child  is  not 
unfrequently  hoUow,  it  is  rarely  cavernous,  and  is  not  accompanied  by 
metallic  gui'gling.  Moreover,  the  cough  is  not  paroxysmal,  and  expectora- 
tion is  scanty  or  absent.  Cirrhosis  of  the  lung  may,  however,  follow  upon 
long-standing  pleurisy.  It  is  detected  by  the  gradual  supervention  of  signs 
of  bronchial  dilatation  with  copious  pui'ulent  sputa. 

If  on  account  of  extreme  dilatation  of  the  bronchi  no  retraction  of  the 
■side  is  present,  the  characteristic  cough,  the  profuse  sputa,  the  sudden 
change  in  the  physical  signs  after  expectoration,  and  the  histoiy  of  repeated 
faUure  of  health,  with  rapid  improvement  under  favourable  conditions  of 
liring,  are  symptoms  of  the  utmost  value. 

Ordinary  pulmonaiy  phthisis  is  usually  combined  with  a  certain  degree 


FIBROID   IlSTDUEATIOlSr   OF  THE  LUNG — TREATMENT.  479 

of  fibroid  overgrowth.  The  distinction  between  dilated  bronchi  and  cavi- 
ties due  to  ulcerative  destruction  of  lung  is  elsewhere  considered  (see  page 
514).  In  any  case  the  strict  limitation  of  the  disease  to  one  side  of  the 
•chest  is  a  strong  argument  in  favour  of  the  fibroid  disease,  for  pulmonary- 
phthisis  in  the  third  stage  is  never  confined  to  one  lung.  It  must  be  re- 
membered that  cavities  resulting  from  ulceration  of  lung  may  be  combined 
with  dilated  bronchi  (fibroid  i^hthisis).  In  such  a  case  the  apex  of  the 
opposite  lung  is  probably  also  the  seat  of  disease.  The  diagTiosis  will  then 
rest  upon  the  history  of  the  illness  and  the  evidence  of  marked  contraction. 

Prognosis. — Although  fibroid  induration  of  the  lung  usually  tends  to 
increase,  the  immediate  prospects  of  the  child  are  not  unfavourable  so  long 
as  the  disease  is  limited  in  extent  and  remains  uncomplicated.  The  danger 
of  these  cases  arises  from  the  secondary  disturbances,  which  are  a  common 
and  unfortunate  consequence  of  this  condition  of  the  lung.  A  catarrh 
causes  great  increase  of  bronchial  secretion,  and  often  leads  to  retention, 
and  decomposition  of  purulent  matter  in  the  dilated  tubes.  The  iri-itation 
thus  induced  may  be  sufficient  by  itseK  to  set  up  a  catarrhal  pneumonia. 
Fortunately  in  these  attacks  the  type  of  the  intercurrent  disease  is  usually 
subacute  ;  but  its  course  is  apt  to  be  protracted,  and  if  the  fibroid  consoli- 
dation is  advanced,  or  the  nutrition  of  the  child  impaired,  the  patient  may 
•succumb  to  the  complication. 

The  continuance  of  healthy  nutrition  is  very  necessary  to  the  favour- 
able progress  of  these  cases,  and  any  derangement  which  tends  to  reduce 
the  strength,  such  as  digestive  distru-bance,  vomiting,  or  diarrhoea,  is  dis- 
tinctly injurious.  The  progress  is  more  favourable  when  the  disease  is 
seated  at  the  upper  part  of  the  lung  than  when  it  occupies  the  base.  In 
the  first  case,  on  account  of  the  downward  direction  of  the  air-tubes, 
retention  of  secretion  is  less  liable  to  occiu-  ;  in  the  second  case  the  force 
■of  gi'avity  helps  to  favour  accumulation  in  the  tubes. 

In  the  later  stage  of  the  illness,  when  amyloid  disease  of  organs  has 
occurred,  the  prognosis  is  serious  ;  but  even  at  this  period,  if  the  patient  be 
living  in  a  chmate  which  allows  him  to  pass  much  of  his  time  in  the  open 
air  without  risk  of  chill,  nutrition  may  be  carried  on  fairly  well.  CEdema 
^th  or  without  amyloid  change  is  an  unfavourable  sign,  as  it  indicates  a 
a  very  unsatisfactory  state  of  the  blood. 

Treatment. — In  the  treatment  of  this  chronic  disease  we  can  do  nothing 
to  remedy  "the  mischief  in  the  lung  so  far  as  it  is  already  completed. 
"Wherever  the  fibroid  change  has  advanced,  the  tissue  affected  is  injured 
b)eyond  hope  of  repair,  and  no  treatment  can  cause  absorption  of  the  mor- 
bid material  in  the  lung.  Still,  we  can  do  much  by  careful  attention  to 
the  conditions  of  life  of  the  child  to  prevent  further  spread  of  the  disease. 
•Our  efforts  must  be  directed  to  the  removal  of  irritation  in  the  lung,  so  .as 
to  arrest  the  tendency  to  active  change,  and  to  the  promotion  of  healthy 
nutrition.  The  chief  cause  of  the  extension  of  the  indurating  process  is 
the  presence  of  bronchial  secretion  in  the  tubes.  We  must  therefore  do 
aU  in  our  power  to  avert  the  risk  of  chill  ;  and  if  a  catarrh  attack  the  lung, 
it  must  be  treated  without  delay.  The  child  must  be  dressed  from  head  to 
foot  in  flannel  or  woollen  underclothing,  and  should  never  leave  the  house 
in  cold  or  damp  weather  without  suitable  covering  to  his  neck  and  chest. 
This  precaution  is  the  more  necessary  as  confinement  to  hot  rooms  is  to  be 
deprecated  ;  and  if  the  child  be  properly  protected  from  cold,  regular  exer- 
cise should  be  insisted  upon.  H  loracticable,  it  is  desirable  that  the  child 
should  pass  the  winter  in  a  dry  and  bracing,  but  equable  climate,  where 
Jie  is  not  liable  to  suffer  from  constant  changes  of  temperature.     His  diet 


480  DISEASE  IlSr   CHILDEEN. 

shoiild  be  nutritious,  consisting  of  meat,  eggs,  milk,  etc.,  avoiding  excess 
of  farinaceous  food  ;  and  if  he  be  weakly,  half  a  glass  of  port  wine,  or  of  the 
St.  Raphael  tannin  wine,  diluted  with  an  equal  quantity  of  water,  may  be 
given  him  with  his  dinner.  Iron  and  cod-liver  oil  are  always  indicated  in 
these  cases. 

Directly  signs  of  catarrh  are  noticed  the  child  must  be  confined  to  his 
bed,  and  be  subjected  to  the  treatment  recommended  for  such  cases  (see 
Bronchitis). 

In  the  more  advanced  stage  of  the  disease  much  may  be  done  by  suit- 
able medication  to  relieve  the  more  distressing  symptoms.  One  of  our 
first  objects  should  be  to  control  the  amount  of  secretion  and  destroy  its 
fetor.  Astringent  remedies  given  by  the  mouth  and  inhaled  into  the  lungs 
are  very  useful  for  this  purpose.  The  child  should  take  quinine  (gr.  j.-ij.), 
with  tinct.  ferri  j)erchloridi  (tT[  x.-xx.)  and  a  fcAV  drops  of  hq.  morphise 
several  times  in  the  day  ;  and  astringent  and  antiseptic  solutions  should  be 
sprayed  into  the  thi'oat  at  suitable  intervals.  These  solutions  must  not  be 
too  strong  or  they  may  excite  so  much  cough  that  their  use  will  have  to 
be  discontinued.  Alum  (gr.  x,  to  the  oz.  of  water)  and  tannin  (half  a  grain 
to  the  oz.)  are  both  very  useful ;  or  we  may  use  carbolic  acid  or  creasote 
( Tli  XX.  to  the  pint  of  hot  water)  combined  with  a  drachm  of  tinct.  benzoini 
CO.  as  an  inhalation.  Turpentine  given  internally  is  often  a  valuable 
remedy  in  diminishing  the  amount  of  secretion.  It  may  be  administered 
in  doses  of  ten  or  twenty  drops  every  three  or  four  hours.  Reducing  the 
quantity  of  fluid  allowed  for  drink  will  often  considerably  diminish  the 
secretion  ;  but  children  do  not  readily  submit  to  this  deprivation. 

Vomiting  is  useful,  as  the  act  helps  to  effect  the  discharge  of  secretion 
from  the  tubes ;  but  the  paroxysms  of  cough  are  apt  to  be  excited  by 
taking  food,  and  if  the  contents  of  the  stomach  are  ejected  shortly  after  a 
meal  the  loss  of  nourishment  may  cause  serious  interference  with  nutrition. 
In  these  cases  it  is  advisable  to  give  small  doses  of  arsenic  (TTj,  j.-ij.)  two  or 
thi'ee  times  a  day,  or  a  drop  or  two  of  liq.  stiychnise,  for  both  of  these 
remedies  tend  to  control  the  retching  efforts  at  the  end  of  a  fit  of  cough- 
ing. But  the  vomiting  should  be  excited  at  a  more  convenient  time,  as  in 
the  early  morning,  by  a  draught  of  warm  water,  mustard  and  water,  or  a 
grain  of  sulphate  of  copper. 

Cod-liver  oil  and  tonics  are  of  great  service  at  all  stages  of  the  disease  ; 
and  if  amyloid  degeneration  of  organs  has  occurred,  and  there  be  anaemia, 
iron  is  especially  indicated.  Dropsy  must  be  treated  on  a  similar  plan. 
Any  compHcations  which  arise  in  the  course  of  the  disease  must  receive 
immediate  attention  ;  for  it  is  indispensable  to  maintain  the  healthy  work- 
ing of  the  animal  functions.  Therefore  indigestion,  diarrhoea,  etc.,  must 
be  treated  by  diet  and  suitable  remedies,  as  directed  in  the  chapters 
treating  of  these  subjects. 


CHAPTER  IX. 

BRONCHITIS. 

INFLAMMATION  of  the  mucous  membrane  lining  the  air-tubes  is  a  com- 
mon cause  of  death  in  infancy  and  childhood.  The  disease  may  be  danger- 
ous not  only  in  itself  but  through  its  tendency  to  be  accompanied  by 
collapse  of  the  lung  or  to  pass  into  broncho-pneumonia.  In  young  infants 
death,  when  it  occurs  in  bronchitis,  is  seldom  due  to  the  uncomplicated 
disease.  It  is  usually  to  be  ascribed  to  one  of  the  consequences  which 
have  been  referred  to.  In  older  children  a  simple  bronchitis  may  prove 
fatal,  but  up  to  the  age  of  five  or  six  years  the  untoward  result  is  commonly 
due  to  extension  of  the  inflammation  to  the  finest  tubes  and  terminal  alveoli. 

Bronchitis  may  be  a  mild  complaint  or  an  affection  of  the  utmost 
gravity.  When  the  disease  attacks  only  the'  large  tubes,  it  is  usually  of 
little  consequence  and  can  be  readily  CTired  by  judicious  treatment, 
although  even  in  these  cases,  if  the  patient  be  a  weakly  infant,  fatal  col- 
lapse may  occur  very  suddenly  and  unexpectedly.  When  the  disease 
spreads  to  the  smaller  tubes  (capillary  bronchitis)  the  illness  is  a  very 
serious  one,  and  many  of  these  cases  prove  fatal. 

Causation. — Bronchitis  may  arise  from  exposure  to  weather  and  to 
changes  of  temperature  like  other  forms  of  catarrhal  derangement.  It 
may  also  be  set  up  by  in-itants  inhaled  into  the  air-passages.  Thus  an 
escape  of  gas  in  the  nursery  is  sometimes  a  cause  of  bronchial  catarrh. 
During  the  pyrexia  attendant  upon  dentition  children  are  especially  sensi- 
tive to  the  causes  of  pulmonary  disorder,  and  very  slight  chills  will  give 
rise  to  bronchitis  in  such  subjects.  Some  children  are  said  always  to  "  cut 
their  teeth  with  a  cough."  In  other  words,  their  exceptional  sensibility  at 
this  time  to  atmospheric  influences  makes  them  catch  cold  very  readily. 

Damp  and  cold  combined,  especially  where  great  variations  of  tempera- 
ture occur,  are  fruitful  causes  of  catarrhal  disorders ;  and  if  in  a  climate 
where  such  conditions  prevail  the  child  is  insufiiciently  clothed,  he  usually 
becomes  a  frequent  sufferer  from  bronchial  derangements.  Some  mothers- 
have  a  curious  dislike  to  flannel  worn  next  to  the  skin,  and  accustom  their 
children  in  all  seasons  to  depend  solely  upon  the  warmth  of  their  frocks 
and  wrappers  for  protection  against  the  cold.  The  common  result  of  such 
a  practice  is  to  increase  the  natural  susceptibility  to  chill ;  and  many  a 
child's  life  has  been  sacrificed  to  this  senseless  prejudice. 

Besides  the  primary  form  of  bronchitis  which  is  induced  by  the  above 
causes,  the  disease  is  frequently  met  with  as  a  secondary  affection.  There 
are  many  forms  of  illness  which  are  habitually  complicated  by  pulmonary 
catarrh.  Whooping-cough,  measles,  typhoid  fever,  and  acute  pulmonary 
tuberculosis  are  amongst  the  number.  In  others  an  intercurrent  bronchi- 
tis is  a  frequent  phenomenon.  Thus  in  scarlatina,  small-pox,  diphtheria, 
certain  special  lung  diseases,  as  croujDous  pneumonia  and  pleurisy,  and 
31 


482  DISEASE  m   CHILDEEN. 

in  diseases  of  the  heart  and  kidneys,  bronchitis  is  a  frequent  complica- 
tion. 

Morhid  Anatoviy. — The  anatomical  changes  induced  by  the  disease  in- 
volve primarily  the  mucous  membrane,  and  may  spread  thence  to  deeper 
structures.  The  membrane  is  congested  and  consequently  reddened  and 
thickened.  Sometimes  it  is  softened.  The  secretion  is  at  first  diminished, 
but  afterwards  becomes  copious  and  watery ;  then  thicker  and  more  like 
pus.  Under  the  microscope  we  find  epithelial  cells  (many  of  them  em- 
bryonic), granular  cells,  and  pus  corpuscles. 

"\\Tien  the  bronchitis  is  capillary,  the  finer  tubes  are  often  found  com- 
pletely occluded  by  this  viscid  muco-pus.  This  is  especially  the  case  in  the 
lower  lobes,  into  which  the  secretion  has  probably  jDcnetrated  by  inhalation 
and  gravitation.  More  or  less  collapse  is  then  usually  found  in  the  tissue 
with  which  the  obstructed  tubes  are  in  connection. 

The  inflammatory  j^rocess  is  at  first  Umited  to  the  mucous  membrane, 
but  if  the  disease  continues,  may  penetrate  to  the  submucous  tissue  or 
even  involve  the  whole  thickness  of  the  bronchial  wall.  In  these  cases  dila- 
tation of  the  channel  may  take  place,  and  acute  enlargement  (emphysema) 
of  the  air-cells  may  be  found.  Often  the  two  opposite  conditions  of  lob- 
ular collapse  and  lobular  emphysema  may  be  found  side  by  side. 

Ulcerative  excavations,  described  by  Dr.  Gairdner  as  "bronchial  ab- 
scesses," sometimes  occur.  These  are  found  in  the  centre  of  collapsed  lob- 
ules, and  consist  of  little  collections  of  pus  the  size  of  a  hemp-seed  or 
larger.  They  communicate  with  the  terminal  tubes,  and  may  be  formed  of 
dilatations  of  these  tubes  or  of  ulcerative  destruction  of  the  walls  of  ad- 
joining ah'-cells.  In  the  former  case  they  are  lined  by  a  fine  villous  mem- 
brane ;  in  the  latter  they  are  minute  cavities  in  the  lung  substance,  and 
their  purulent  contents  lie  in  immediate  contact  with  the  lung  tissue. 
According  to  Dr.  Gairdner,  these  purulent  collections  are  the  direct 
result  of  pus  accumulated  primarily  in  the  extreme  bronchial  tubes  of 
the  collapsed  lobules.  The  general  appearance  of  these  abscesses  is 
that  of  softening  tubercles,  for  which,  indeed,  they  have  been  often  mis- 
taken. 

In  the  majority  of  cases  bronchitis  is  limited  to  the  larger  tubes,  but 
even  then  the  purulent  secretion  may  be  di-awn  inwards  into  the  fine  bron- 
chi ;  and  these  are  often  found  fiUed  with  viscid,  yellow  matter,  even  when 
their  lining  membrane  is  not  inflamed.  In  young  infants,  who  cannot 
cough  at  wiU,  this  retention  is  very  liable  to  occur,  and,  as  is  elsewhere  ex- 
plained, is  one  of  the  causes  which  render  collapse  of  the  lung  so  common 
a  lesion  in  the  beginning  of  life. 

Besides  the  anatomical  characters  which  have  been  described,  spots  of 
catarrhal  pneumonia  are  very  common.  The  appearances  resulting  from 
this  form  of  disease  and  the  mode  of  its  production  are  described  elsewhere 
(see  catarrhal  pneumonia). 

In  chronic  bronchitis  the  mucous  membrane  often  appears  to  be  little 
affected,  although  sometimes  it  is  smooth  and  polished.  The  smaller  tubes 
are  considerably  dilated  ;  their  transverse  fibres  are  hypertrophied  ;  and 
the  sub-mucous  connective  tissue  is  generally  thickened.  Considerable 
emphysema  is  usually  met  with,  and  collapse  is  an  almost  invariable  f eatvu-e 
of  this  form  of  the  disease. 

Symptoms. — When  the  inflammation  is  confined  to  the  larger  bronchi, 
the  symptoms  are  not  severe  unless  the  patient  be  a  veiy  young  or  weakly 
subject.  In  a  new-born  child  or  a  feeble,  wasted  infant  a  slight  degree  of 
bronchial  catan'h  may  be  accompanied  by  very  serious  symptoms,  and  even 


BRONCHITIS — SYMPTOMS.  483 

lead  to  death  from  the  occurrence  of  pulmonary  collapse.     This  form  of 
the  disease  is  described  elsewhere  (see  Collapse  of  the  Lung). 

In  stronger  infants  and  older  children  the  occurrence  of  catarrh  of  the 
larger  bronchi  is  indicated  by  coryza  and  cough.  The  child  sneezes  and 
coughs  at  intervals.  He  complains  of  no  pain,  and  if  the  cough  is  hard  at 
the  first  it  soon  becomes  loose,  and  ceases  after  a  few  days.  In  these  mild 
cases  the  general  symptoms  are  slight  or  wanting.  There  is  no  fever  ;  the 
child  is  lively  and  cheerful,  and  his  appetite  is  little  impaired.  The  tongue 
is  usually  furred,  and  there  is  some  costiveness  ;  but  an  aperient  powder 
soon  remedies  this  inconvenience,  and  the  child  is  quickly  well.  In  such 
cases  the  only  j)hysical  sign  to  be  detected  about  the  chest  is  the  presence 
of  a  little  sonoro-sibilant  rhonchus  or  an  occasional  large  bubble  in  the 
inter-scapular  region. 

Although  these  cases  are  mild  in  themselves  and  easily  cured,  they  may 
yet,  by  neglect,  be  so  j)rolonged  as  to  cause  considerable  interference  vnth 
nutrition.  If  care  be  not  taken  to  protect  the  patient  from  the  ordinary 
causes  of  chill,  he  may  pass  through  a  succession  of  little  colds,  so  that  his 
cough  continues  for  several  weeks,  and  may  be  accompanied  by  a  certain 
amount  of  catarrh  of  the  stomach.  Consequently,  the  child  looks  pale  and 
gets  flabby  and  languid.  In  such  a  state  his  condition  may  not  only  be 
considered  an  anxious  one  by  his  parents,  who  begin  to  entertain  fears  of 
consumption,  but  the  resisting  power  of  the  child  against  changes  of  tem- 
perature being  really  lowered,  he  is  very  aipt  to  alarm  the  practitioner  by 
suddenly  developing  aU  the  symptoms  of  acute  broncho-pneumonia. 

If  the  catarrh  assume  a  severe  form,  it  often  begins  with  fever  and 
soreness  behind  the  sternum.  The  temperature  rises  to  100°  or  101°;  the 
tongue  is  thickly  furred  ;  the  pulse  and  respiration  are  both  hurried,  al- 
though their  relation  to  one  another  is  little  altered  ;  and  the  bowels  are 
confined.  The  nares  act  with  respiration.  The  cough  is  at  first  hard  and 
frequent  and  increases  the  pain  in  the  chest.  The  skin  is  moist,  the  face 
flushed,  and  the  child,  if  an  infant,  constantly  requu'es  to  be  in  his  nurse's 
arms.  He  is  very  thirsty,  and  on  this  account  takes  his  bottle  with  eager- 
ness. A  certain  amount  of  gastrointestinal  catarrh  often  accompanies  the 
bronchitis.  The  child  may  vomit,  and  his  bowels  are  often  relaxed.  Usu- 
ally, after  a  day  or  two  the  temperature  subsides,  the  cough  becomes 
looser,  and  the  soreness  of  the  chest  abates.  Under  proper  treatment,  the 
child  is  usually  well  at  the  end  of  the  week. 

The  physical  signs  in  these  cases  are  of  trifling  amount.  They  consist 
merely  in  more  or  less  large  bubbhng  at  each  base,  with  dry  rhonchus  and 
occasional  bubbling  rales  at  various  parts  of  the  lungs. 

"When  the  inflammation  penetrates  into  the  smaller  tubes  (capillary 
bronchitis)  the  symptoms  become  alarming.  The  features  look  pinched, 
and  the  exjDression  is  one  of  extreme  distress.  The  face  is  pale,  with  much 
lividity  about  the  eyelids  and  mouth.  The  child  is  restless.  His  dysp- 
noea is  great,  and  his  respiratory  movements  are  laboured  as  well  as  hur- 
ried ;  but  if  the  disease  is  uncomplicated  with  coUapse  or  lobular  pneumo- 
nia, there  is  little  disturbance  of  the  normal  proportion  between  the  pulse 
and  respiration.  Often  the  child  is  subject  to  suffocative  spasms  if  laid 
down,  and  has  to  be  supported  partially  upright  in  his  nurse's  arms,  or 
raised  in  his  cot  by  pillows.  At  each  inspiration  considerable  recession  is 
noticed  of  the  soft  parts  of  the  chest  ;  and  if  the  ribs  are  yielding  from 
rickets,  the  retraction  of  the  bases  of  the  chest  may  be  extreme.  The  tem- 
perature at  first  is  raised  to  101°  or  102°,  but  when  aeration  of  the  blood 
is  greatly  interfered  with  the  mercury  usually  sinks  to  99°. 


484  DISEASE   IN   CHILDREN. 

The  pulse  rises  to  140  or  150,  or  even  liigher,  and  is  small  and  often 
hai'd.  The  cough  is  hacking  and  hoarse,  and  occurs  in  stifling  paroxysms, 
greatly  increasing  the  difficulty  of  breathing  and  intensifying  the  lividity 
of  the  face.  The  skin  is  moist  and  beads  of  sweat  are  often  seen  stand- 
ing upon  the  brows.  The  tongue  is  moist  and  thickly  furred.  Appetite 
is  completely  lost  and  the  child  is  very  thirsty.  Still,  on  account  of  the 
dyspnoea  an  infant  is  quite  unable  to  draw  fluid  fi'om  a  bottle.  The 
mouth  is  required  as  an  air-passage,  and  the  needs  of  respiration  preclude 
its  being  used  for  any  other  purpose.  Vomiting  sometimes  follows  a  par- 
oxysm of  cough,  and  much  whitish  or  yellowish  phlegm  is  thrown  up  with 
the  contents  of  the  stomach.  In  this  state  the  child  rarely  speaks  or  cries. 
Crying  interferes  with  respiration,  and  he  has  no  breath  to  spare. 

On  examination  of  the  chest  percussion  discovers  no  dulness.  With 
the  stethoscope  the  breath  sounds  are  found  to  be  more  or  less  completely 
covered  by  a  copious  sub-crepitant  rhonchus  which  is  heard  over  both  lungs. 
In  an  uncompHcated  case  the  breathing  is  nowhere  bronchial  or  blowing, 
and  the  resonance  of  the  voice  is  unaltered.  These  cases  are,  however,  so 
often  complicated  vrith  atelectasis  or  broncho-pneumonia  that  the  physical 
signs  connected  with  these  forms  of  disease  are  often  to  be  detected  at  the 
posterior  bases. 

Unless  an  amelioration  in  the  symptoms  occurs  suddenly,  the  distress 
becomes  more  and  more  marked.  The  fits  of  dj^spnoea  are  more  frequent 
and  alarming.  The  child,  as  long  as  his  strength  will  allow,  tosses  in  his 
bed,  throwing  his  arms  about  restlessly.  In  an  infant  or  rickety  child  the 
symptoms  pass  on  to  those  which  have  been  described  as  characteristic  of 
atelectasis  or  of  catarrhal  pneumonia.  In  older  children,  in  whom  these 
complications  are  less  likely  to  occur,  the  face  assumes  a  leaden  hue ;  the 
fingers  and  nails  grow  purple ;  the  breathing  is  more  hurried,  and  the  pulse 
gets  excessively  rapid  and  small.  As  the  weakness  and  asphj'xia  become 
more  marked  the  coagh  ceases  ;  the  restlessness  diminishes  ;  the  child  be- 
comes drowsy  and  intensely  apathetic,  and  soon  dies  comatose  or  con- 
vulsed. The  temperature  often  sinks  to  a  normal  level  when  the  symptoms 
of  asphyxia  become  more  pronounced,  but  often  rises  again  before  death 
to  102°  or  103°. 

If  the  case  terminate  favourably,  the  eyes  grow  brighter  and  the  livid- 
ity begins  to  clear ;  the  cough  is  looser  and  less  paroxysmal ;  the  pulse 
slackens  ;  the  breathing  is  less  laboured  ;  and  the  child  takes  more  notice, 
seeming  to  be  less  absorbed  in  his  own  uneasy  sensations. 

The  chronic  form  of  bronchitis  is  not  rare  at  the  age  of  five  or  six 
years  and  upwards.  It  usually  occurs  in  children  of  scrofulous  tendencies 
who  have  been  subject  to  repeated  attacks  of  bronchial  catarrh,  and  suffer 
in  consequence  from  some  permanent  emphysema  of  the  lungs.  Such 
children  are  very  sensitive  to  chills,  and  are  apt  to  be  troubled  in  the 
changeable  seasons  of  the  year  with  a  distressing  cough  and  shortness  of 
breath.  Measles  and  pertussis  in  strumous  subjects  are  often  followed  by 
the  same  pulmonar}^  susceptibility,  so  that  during  the  colder  months  the 
patients  wheeze  and  cough,  and  present  all  the  symptoms  of  chronic  bron- 
cl;iitis  such  as  result  from  the  same  conditions  in  elderly  persons. 

In  the  milder  form  of  the  disease  the  child  merely  suffers  from  a 
chronic  cough,  which  undergoes  very  noticeable  exacerbations  on  any 
change  of  the  weather,  and  on  the  occurrence  of  a  chill  is  complicated  for 
a  time  by  the  symptoms  of  an  acute  attack  of  pulmonary  catarrh.  These 
cases  often  give  much  trouble  and  are  very  difficult  of  cure. 

In  a  severer  form,  when  the  emphysema  is  marked,  the  chest  becomes 


BRONCHITIS — SYMPTOMS — DIAGNOSIS.  485 

barrel-shaped ;  the  skin  is  habitually  dry  and  the  fingers  are  slightly 
clubbed.  These  children  are  almost  invariably  short  and  thick-set,  with 
coarse  features,  thick  turgid  lips,  broad  shoulders,  and  large  bones.  They 
often  stoop  as  they  walk.  During  the  summer  months  they  are  fairly  well, 
with  a  good  appetite  ;  and  although  they  may  pant  after  exertion,  do  not 
suffer  from  noticeable  shortness  of  breath.  In  the  winter  they  have  a  per- 
sistent cough,  and  cannot  indulge  in  noisy  games,  as  much  movement  pro- 
duces instant  dyspnoea.  The  cough  is  loose  and  paroxysmal ;  sometimes 
they  expectorate  frothy,  yellow  phlegm.  The  face  is  usually  livid  and 
puffy-looking.  The  appetite  is  capricious,  and  vomiting  is  frequent  after 
cough.     The  bowels  are  costive. 

On  examination  of  the  chest  we  find  general  hyper-resonance  ;  and  the 
respiratory  sounds  are  more  or  less  concealed  by  a  fine  crackling  rhonchus. 
If,  as  often  happens,  there  is  dilatation  of  the  bronchi,  the  respiration  in  the 
inter-scapular  region  may  be  bronchial  or  even  cavernous.  As  a  rule  the 
temperature  is  normal. 

Chronic  catarrh  of  the  stomach  or  bowels,  or  both,  often  occurs  in  these 
cases.  The  appetite  is  poor ;  the  bowels  are  loose  and  contain  much 
mucus  ;  and  the  loss  of  flesh  is  rapid.  With  great  care  the  pulmonary 
catarrh  may  be  kept  under,  and  if  the  child's  strength  be  properly  sup- 
ported, life  may  be  prolonged  until  the  return  of  more  genial  weather,  when 
the  patient  very  quickly  begins  to  improve.  In  too  many  cases,  however, 
death  ensues  as  a  consequence  of  an  intercurrent  attack  in  which  the  tem- 
perature rises,  and  the  symptoms  which  have  been  described  as  the  conse- 
quence of  capillary  bronchitis  are  noticed. 

A  boy,  aged  thirteen  years,  both  of  whose  parents  were  said  to  be  "  weak 
in  the  chest,"  was  healthy  up  to  the  age  of  eight  years,  when  he  had  an 
attack  of  measles  followed  by  pertussis.  From  that  time  he  suffered  from 
cough  which  was  always  worse  in  the  winter.  He  was  admitted  into  the 
Victoria  Park  Hospital  in  February  for  a  severe  bronchitis. 

The  boy  was  fairly  nourished  and  well  built,  although  short  for  his  age. 
His  chest  was  full  and  expanded  above,  but  at  the  lower  part  on  each  side 
there  was  some  infra-mammary  depression.  The  spine  was  straight.  The 
heart's  apex  was  in  the  fifth  interspace,  three  quarters  of  an  inch  to  the 
inner  side  of  the  nipple  line.  Its  impulse  could  be  also  felt  in  the  epigas- 
trium. The  skin  was  dry  and  harsh  ;  the  fingers  were  slightly  clubbed  ; 
the  liver  and  spleen  seemed  pushed  downwards.  The  face  was  congested, 
turgid,  and  more  or  less  livid.  The  breathing  was  laboured,  and  the  boy 
could  not  lie  down  in  his  bed.  The  temperature  was  normal  and  the 
urine  healthy. 

On  examination  of  the  chest  the  percussion  note  generally  was  hyper- 
resonant  ;  and  everywhere  over  the  chest  the  bi'eath  sounds  were  concealed 
by  a  copious,  fine,  crackling  rhonchus.  This  at  the  base  was  very  super- 
ficial and  ringing.  The  boy  remained  in  the  hospital  until  June,  being 
sometimes  better,  sometimes  worse  ;  and  the  amount  of  rhonchus  varied 
considerably  from  time  to  time.  The  temperatui-e  rarely  rose  above  99°. 
On  his  discharge,  although  his  breathing  was  much  better  and  his  general 
condition  fairly  good,  much  rhonchus  remained  at  the  bases  of  the  lungs. 

Diagnosis. — There  is  little  difiiculty  about  the  diagnosis  of  bronchitis. 
In  the  milder  form  a  mistake  is  hardly  possible  unless  from  teething  or 
other  cause  there  is  a  high  degree  of  fever.  With  considerable  pyrexia 
the  derangement  may  be  mistaken  for  measles  or  broncho-pneumonia. 
In  the  first  case  the  occurrence  of  the  characteristic  rash  on  the  fourth  day 
will  clear  up  the  difiiculty.     In  the  second,  the  absence  of  distress  in  the 


486  DISEASE  ijsr  childeen. 

face,  the  normal  pulse-respiration  ratio,  and  tlie  limited  amount  of  rlion- 
chus  detected  by  the  ear  will  furnish  a  sufficient  distinction. 

In  capillary  bronchitis  the  laboured  breathing,  the  thick  and  often 
paroxysmal  cough,  the  copious  mucous  rales  heard  with  the  stethoscope, 
combined  with  the  absence  of  dulness  on  percussion  and  of  bronchial  or 
blowing  breathing,  are  sufficiently  distinctive.  A  point  of  great  importance 
is  the  exclusion  of  atelectasis  and  of  catarrhal  pneumonia.  The  new  feat- 
ures introduced  into  the  case  by  the  occurrence  of  either  of  these  complica- 
tions are  referred  to  elsewhere  (see  pages  467  and  436 ). 

Prognosis. — As  long  as  the  catarrh  remains  limited  to  the  larger  tubes 
the  prognosis  dejDends  upon  the  age  and  general  strength  of  the  patient. 
However  slight  the  disorder  may  be,  we  can  never  feel  sure  that  in  a  new- 
born, a  weakly,  or  a  rickety  infant  fatal  collapse  of  the  lung  may  not  follow 
unexpectedly.  In  all  such  cases,  therefore,  we  should  warn  the  parents  of 
this  possible  danger,  and  caution  them  to  watch  carefully  for  lividity, 
drowsiness,  or  other  sign  indicating  insufficient  aeration  of  the  blood. 

In  capillary  bronchitis  the  danger  is  great,  however  healthy  the  child 
may  have  previously  been  ;  and  if  the  patient  be  weakly  or  the  subject  of 
rickets,  the  peril  is  really  urgent.  Indeed,  few  such  cases  recover.  The  ex- 
tremity of  the  danger  is  indicated  by  a  high  degree  of  interference  with 
the  aeration  of  the  blood.  If  the  child  become  intensely  apathetic  or  irre- 
sistibly drowsy,  with  bhaeness  of  finger-ends,  an  ashy-gray  face,  dull  and 
lustreless  eyes,  and  a  normal  or  sub-normal  temperature,  death  can  scarcely 
be  avoided.  Other  signs  of  unfavourable  import  are  suppression  of  the 
cough,  great  rapidity  of  the  pulse  and  respiration,  smallness  of  pulse  and 
fulness  of  superficial  veins,  with  retraction  of  the  base  of  the  chest  in  in- 
spiration. 

Signs  indicative  of  collapse  of  the  lung  or  of  broncho-pneumonia  augur 
iU  for  the  child's  chances  of  recovery. 

Treatment. — A  pulmonary  catarrh  in  a  child,  especially  if  the  patient  be 
weakly  or  of  a  rickety  constitution,  should  never  be  treated  lightly.  In  the 
mildest  case  the  patient  should  be  kept  in  his  room  and  be  made  to  take  a 
saline  mixture  containing  a  few  drops  of  ipecacuanha  or  antimonial  wine 
in  each  dose.  If  there  is  any  rise  of  temperature,  he  should  be  at  once 
put  to  bed.  This  is  essential.  Perfect  quiet  is  necessary  for  a  feverish 
child  ;  and  even  if  pyrexia  be  absent,  the  repose  and  equable  temperature 
of  his  cot  will  hasten  the  patient's  recovery  more  certainly  than  the  most 
energetic  medication.  Indeed,  without  this  precaution  treatment  loses  more 
than  half  its  value.  In  the  next  place  we  must  employ  counter-irritation. 
There  is,  however,  a  right  and  a  wrong  way  even  of  using  a  poultice. 
"Weak  applications  in  these  cases  are  better  than  strong  irritants  ;  for  a  far 
more  effectual  impression  is  made  by  acting  slowly  upon  a  large  surface 
of  the  skin,  than  by  producing  a  more  violent  irritation  of  a  comparatively 
limited  area.  One  part  of  mustard  should  be  diluted  with  five  or  six  times 
its  bulk  of  finely  ground  linseed  meal.  The  ingredients  should  be  care- 
fully mixed  in  the  dry  state  and  made  into  a  poultice  with  hot  but  not 
boiling  water.  The  application  should  be  sufficiently  large  to  cover  the 
whole  front  of  the  chest,  and  should  be  allowed  to  remain  in  contact  with 
the  skin  for  six  or  eight  hours,  or  even  longer  if  the  child  can  bear  it.  A 
layer  of  cotton  wool  should  be  then  applied  in  its  place,  and  a  fi'esh  poul- 
tice of  similar  strength  should  be  made  for  the  back  and  be  kept  on  for  an 
equal  period  of  time.  An  infant  will  bear  this  strength  well.  For  an 
older  child  a  larger  proportion  of  mustard  may  be  used  ;  but  it  is  seldom 
wise  to  employ  an  application  which  cannot  be  borne  for  at  least  six  hours. 


BRONCHITIS — TREATMENT.  487 

The  effect  of  these  measures  is  seen  very  quickly.  In  the  milder  forms  of 
the  disease  the  hard  cough  becomes  soft  and  loose,  the  soreness  of  the 
chest  subsides,  and  the  pyrexia  quickly  disappears.  Even  in  the  more 
severe  variety  a  sensible  diminution  in  the  distress  and  the  labour  of 
breathing  is  usually  manifested  when  the  skin  becomes  very  red  from  the 
action  of  the  irritant. 

The  diet  should  consist  of  milk  and  broth ;  and  the  child  should  be 
allowed  to  drink  freely  of  thin  barley-water. 

For  medicine,  a  grain  of  calomel  should  be  given  in  a  little  sugar,  and 
be  followed  after  a  few  hours  by  a  dose  of  castor-oil  or  other  mild  aperi- 
ent. A  febrifuge  mixture  can  then  be  prescribed,  such  as  citrate  of  potash 
or  the  solution  of  acetate  of  ammonia  with  a  few  drops  of  ipecacuanha  or 
antimonial  wine.  A  pleasant  form  in  which  these  can  be  given  is  the  fol- 
lowing : — 

3  •  Vi^i  ipecacuanhas TTl,  v. 

Liq.  ammonise  acetatis Til.  x. 

Glycerini fT],  xv. 

Aquam  florae  aiirantii ad  3  ]• 

M.     Ft.  haustus. 

Sig.     To  be  taken  every  four  hours. 

The  above  is  suitable  to  an  infant.  For  older  children  the  proportions 
may  be  increased,  or  the  draught  can  be  given  more  frequently. 

Unless  the  bronchitis  be  severe,  the  bronchial  derangement  quickly 
yields  to  this  treatment  and  the  patient  is  soon  convalescent.  If  the  cough 
continue  after  it  has  become  loose,  and  the  child's  appetite  has  returned,  a 
few  drops  of  paregoric  and  tincture  of  squill  added  to  the  mixture  will 
soon  effect  its  removal.  Stimulating  expectorants  are  as  useful  at  the 
later  stage  of  the  catarrh,  after  the  cough  has  become  loose  and  easy,  as 
they  are  injurious  at  an  earlier  period  when  it  is  hard  and  painful. 

In  capillary  bronchitis  the  child  should  wear  a  flannel  night-dress,  and 
the  temperature  of  his  room  should  be  kept  at  70°  or  75°.  It  is  also  ad- 
visable to  moisten  the  air  round  his  cot  by  vapour  from  one  of  the  many 
varieties  of  bronchitis  kettle,  or  by  Dr.  K  J.  Lee's  "  steam-draught  inhaler." 
The  poulticing  of  the  chest  should  be  carried  out  energetically  ;  and  when 
the  skin  can  no  longer  bear  the  irritant,  the  chest  should  be  vsrrapped  in 
cotton  wool. 

In  this  severe  form  of  the  disease  stimulant  expectorants  are  not  only 
useless  as  remedial  agents,  but  tend  directly  to  increase  the  congestion 
and  irritation  of  the  mu.cous  membrane.  However  feeble  the  child  may 
be,  if  the  cough  is  hard  and  the  chest  tight,  ammonia,  squill,  tolu,  and  other 
remedies  which  exercise  a  stimulating  effect  upon  the  mucous  membrane 
should  be  avoided.  In  such  cases  the  distress  of  the  patient  is  most  cer- 
tainly relieved  and  his  strength,  improved  by  medicines,  such  as  salines 
with  ipecacuanha,  which  promote  free  secretion  from  the  tubes.  If  neces- 
sary, this  treatment  can  be  supplemented  by  general  stimulants,  such  as 
alcohol ;  and  in  weakly  children  it  is  very  necessary  to  counteract  any  de- 
pressing effect  of  the  remedies  upon  the  system  by  the  free  administration 
of  brandy-and-egg.  In  young  children  whose  strength  is  good  it  is  often 
useful  at  the  earlier  periods  of  the  disease,  when  the  cough  is  hard  and 
much  soreness  is  complained  of  in  the  chest,  to  give  two  or  three  grains  of 
powdered  ipecacuanha  in  a  teaspoonful  of  mucilage  twice  a  day  on  an 
empty  stomach.     The  emetic  in  these  small  doses  excites  vomiting  with 


488  DISEASE  IN   CHILDREN. 

very  little  effort,  and  causes  tlie  expulsion  of  much  mucus  from  the  stomach 
and  lungs.  After  a  few  doses  of  this  remedy  the  character  of  the  cough 
often  undergoes  a  marked  change  for  the  better,  and  the  distress  of  the 
patient  is  greatly  reheved.  So  long,  therefore,  as  there  is  fever  with  hard 
cough,  tightness  behind  the  sternum,  and  hvidity  of  the  face,  we  should 
confine  oiu'selves  to  ipecacuanha  or  antimonial  wines  (TTL  v.-x.),  citrate  of 
potash  (gT.  iij.-v. ),  solution  of  acetate  of  ammonia  (tT[  x-xsx.),  spirits  of 
nitrous  ether  (TIj,  x.-sxx.),  and  similar  remedies. 

Although  the  medicines  recommended  are  all  such  as  aid  the  free  secre- 
tion of  mucus,  they  are  not  given  with  any  object  of  producing  deiDression. 
On  the  contrary,  we  should  watch  the  jDatient  carefully  for  signs  of  prostra- 
tion, and  hold  oui'selves  in  readiness  to  correct  any  undue  sedative  influence 
by  alcohohc  stimulation.  We  must  not,  however,  be  in  a  huriy  to  give  wine 
or  brandy.  A  small  feeble  pulse  will  be  often  found  to  become  fuller  and 
stronger  as  secretion  from  the  inflamed  mucous  membrane  becomes  more 
copious  and  the  congestion  of  the  pulmonary  vessels  dechnes. 

In  children  of  four  or  five  years  old  and  upwards  a  grain  of  calomel  with 
two  or  three  grains  of  jalapine  at  the  beginning  of  the  treatment  is  always 
useful.  It  is  unnecessarj'  to  keep  up  a  fr-ee  action  of  the  bowels,  for  these 
cases  appear  to  be  little  benefited  by  pui'ging;  but  a  thorough  unloading 
of  the  liver  is  very  useful  as  a  prehminary  measure.  Even  in  infants  half 
a  grain  of  calomel  followed  by  a  teaspoonful  of  castor  oil  often  seems  to 
render  the  after-course  of  the  disease  milder  and  more  tractable. 

The  above  method  of  treatment  will  usually  be  found  successful  in  cases 
of  primary  capillary  bronchitis,  when  the  patient  is  seen  before  collapse  of 
the  lung  has  occiu-red  or  the  disease  has  passed  into  a  chronic  broncho- 
pneumonia.  It  is  important  that  we  should  not  allow  ourselves  to  be 
tempted,  by  the  ajDparent  prostration  of  the  patient,  to  prescribe  ammonia 
and  other  stimulating  drugs.  When  the  pulmonary  vessels  are  congested 
and  the  obstruction  to  the  circulation  is  extreme,  the  heart  labours,  the 
face  is  li^id,  and  the  pulse  is  small  and  feeble  ;  but  these  symptoms  con- 
stitute no  real  indication  for  ammonia.  We  shall  best  relieve  the  impedi- 
ment to  the  pulmonary  cu-culation  and  promote  the  aeration  of  the  blood 
by  measures  which  relieve  the  congestion  by  producing  free  secretion  from 
the  overloaded  vessels. 

OjDium  should  not  be  given  unless  the  restlessness  is  great,  and  even 
then  the  remedy  is  hardly  a  judicious  one  ;  for  anything  which  dulls  the 
sensibility  of  the  bronchial  mucous  membrane  hinders  the  expulsion  of 
the  phlegm  and  favoru'S  collapse  of  the  air-cells.  Aconite,  veratrum  viiide, 
and  other  powerful  cardiac  sedatives  are  only  admissible  during  the  first 
forty-eight  hours,  and  must  on  no  account  be  given  to  young  infants. 

In  capillary  bronchitis,  as  in  the  case  of  the  milder  forms  of  the  dis- 
ease, when  the  cough  is  quite  loose  and  secretion  free,  small  doses  of 
morphia  or  paregoric,  with  ammonia  and  infusion  of  senega  or  serpentaria, 
wiU  soon  bring  the  disease  to  a  favourable  ending.  Profuseness  of  secre- 
tion at  a  late  stage  of  the  illness  is  an  indication  for  small  doses  of  iron. 
In  infants,  perhaps  a  few  drops  of  sal  volatile  make  the  better  remedy  ; 
but  after  this  age  the  administration  of  four  or  five  grains  of  the  citrate  of 
iron  with  a  drop  or  two  of  liq.  moi-phise,  and  a  few  grains  of  the  bi-carbon- 
ate  of  soda,  is  attended  with  great  benefit.  So,  also,  a  grain  of  quinine 
with  a  couple  of  drops  of  dilute  nitric  acid,  and  the  same  quantitj^  of  laud- 
anum or  solution  of  morphia,  given  several  times  in  the  day,  will  soon 
brace  up  the  relaxed  mucous  membrane  and  diminish  the  frequency  of  the 
cough.  ■    These  remedies  must  of  course  be  confined  to  the  later  stage  of 


BEONCHITIS — TREATMENT.  489 

the  disease,  after  the  pyrexia  has  subsided,  and  when  secretion  is  copious 
from  want  of  tone. 

In  all  forms  of  bronchial  catarrh  in  weakly  infants  or  rickety  children 
the  patient  should  be  carefully  watched  for  signs  of  collapse  of  the  lung. 
If  we  notice  the  child  suddenly  to  become  drowsy,  and  find  that  this  change 
is  associated  with  hvidity  of  the  face,  very  rapid  and  shallow  breathing, 
and  a  fall  of  temperature  to  a  sub-normal  level,  energetic  measures  should 
be.  taken  to  promote  re-expansion  of  the  collapsed  lobules  (see  Atelectasis). 

A  secondary  bronchitis,  such  as  that  which  is  apt  to  occur  in  the  sub- 
jects of  rickets,  must  be  treated  upon  the  same  principles  ;  but  in  these 
cases  alcohohc  stimulation  is  usually  required  early. 

In  chronic  bronchitis  the  child  should,  if  possible,  be  sent  away  for  the 
winter  to  a  mild  climate  where  he  can  pass  his  time  out  of  doors  without 
risk  of  chill.  A  sea  voyage  is  very  beneficial  to  these  patients.  As  this 
form  of  the  disease  usually  occurs  in  scrofulous  children,  the  general  treat- 
ment which  has  been  recommended  for  that  constitutional  condition  should 
be  put  in  force. 

The  intercurrent  acute  attacks  must  be  treated  upon  the  principles 
which  have  been  ah-eady  indicated.  Still,  after  the  disease  has  returned  to  its 
ordinary  chronic  course  expectoration  is  often  very  difiicult,  and  the  breath- 
ing oppressed  ;  and  with  the  stethoscope  we  hear  much  large  bubbling  at 
the  bases  and  for  a  considei'able  distance  over  both  lungs.  In  these  cases 
the  ordinary  expectorants  seem  to  exercise  little  influence  unless  combined 
with  tonics.  Quinine  or  quinine  and  iron,  given  with  tinctin-e  of  squill, 
ipecacuanha,  and  a  drop  or  two  of  solution  of  morphia  will  often  be  found 
successful  in  relieving  the  symptoms.  Cod-liver  oil  is  also  of  great  value  not 
only  in  improving  the  general  health,  but  also  in  checking  secretion  and 
promoting  the  expulsion  of  phlegm.  Tar  taken  internally  has  sometimes 
a  marked  influence  in  checking  secretion  and  giving  a  more  healthy  tone  to 
the  mucous  membrane.  A  droj)  of  liquid  tar  may  be  given  on  a  small 
lump  of  sugar  two  or  three  times  in  the  day  ;  or  for  children  who  can  take 
pills  the  remedy  may  be  given  as  follows  : 

.  ]J .    Picis  liquidse , gi*-  ij- 

Xiycopodii 8'^-  j- 

Pulv.  glycyrrhizse gr.  ss. 

Glycerini q.  s. 

M.   Ft.  pilula. 

Sig.    To  be  taken  three  or  four  times  a  day. 

Inhalations  are  of  service  in  these  cases.  The  vapour  of  hot  water  im- 
pregnated with  creasote,  carbolic  acid,  or  tincture  of  iodine  (of  either 
twenty  drops  to  the  pint),  or  of  oil  of  turpentine  (one  drachm  to  the  pint), 
can  be  inhaled  for  half  an  hour  several  times  in  the  day  from  Dr.  E.  J. 
Lee's  "  steam-draught  inhaler." 

The  hypodermic  injection  of  pilocarpine  is  often  useful.  In  the  case 
of  the  boy  referred  to  above,  one-fifteenth  of  a  grain  of  the  hydi'ochlorate 
of  pilocarpine  was  injected  under  the  skin  twice  a  day.  The  remedy 
caused  copious  sweating,  and  produced  vomiting  by  which  much  miicus 
was  expelled  from  the  lungs.  The  effect  of  the  drug  was  decided  in 
diminishing  for  a  time  the  amount  of  secretion,  although  it  produced 
little  permanent  impression  upon  the  disease. 

Counter-irritation  of  the  chest  with  the  tincture  or  liniment  of  iodine 


490  DISEASE   IN   CHILDEEN. 

is  often  attended  with  great  benefit ;  and  warm  woollen  clothing  worn 
next  to  the  skin  is  essential  to  improvement.  Still,  in  spite  of  all  our 
efforts,  although  the  child  may  appear  better  for  the  time,  a  cure  is  hardly- 
possible  in  pronounced  cases  so  long  as  the  patient  remains  in  a  cold, 
damp  climate.  His  only  hope  of  throwing  off  the  disease  lies  in  his 
removal  to  a  suitable  air  where  he  is  not  exposed  to  the  constant  risk  of 
chill,  and  where  no  untoward  conditions  are  present  to  interfere  with  his 
favourable  progress. 


CHAPTER  X. 

EMPHYSEMA. 

Pulmonary  emphysema  is  not  uncommon  in  the  child.  As  an  acute 
lesion  it  is  of  frequent  occurrence,  arising  in  the  course  of  various  forms 
of  pulmonary  disease.  It  is  then  of  Uttle  consequence,  is  accompanied  by 
few  symptoms,  and  usually  subsides  when  the  primary  complaint  has 
disappeared.  As  a  chronic  affection  emphysema  is  met  with  much  more 
rarely  in  early  life  ;  but  a  child  so  afiflicted  presents  all  the  symptoms 
common  to  the  adult  sufferer,  and  may  have  his  health  permanently  in- 
jured and  his  life  considerably  shortened  by  this  condition  of  his  lung. 
The  lesion  may  be  seen  both  in  the  vesicular  and  interlobular  forms,  and 
has  been  found  at  all  periods  of  childhood,  even  in  new  born  infants. 

Gauaation. — Pulmonary  emphysema  is  always  a  secondary  disease,  and 
appears  to  be  mainly  due  to  forcible  distention  of  the  air-cells  in  the  act 
of  coughing.  It  is  found  in  various  forms  of  lung  disease,  especially  in 
whooping-cough,  bronchitis,  and  catarrhal  pneumonia.  Of  these  the  vio- 
lent cough  of  pertussis  and  catarrhal  pneumonia  produce  the  lesion  with 
the  greatest  certainty,  and  emphysema  is  a  constant  comj)lication  of  every 
severe  attack  of  these  two  diseases. 

It  seems  probable  that  over-distention  of  the  air-cells  in  these  cases 
may  be  effected  both  by  inspiratory  and  expiratory  mechanism.  In 
whooping-cough  and  bronchitis  many  air-vesicles  are  rendered  impervious 
by  patches  of  disseminated  collapse.  In  lobular  pneumonia  considerable 
portions  of  lung  may  be  closed  to  the  entrance  of  air.  In  all  these  cases 
the  diminution  in  the  respiratory  surface  necessitates  increased  energy  of 
inspiratory  movement,  so  that  the  air-vesicles  which  remain  pervious  are 
over-distended.  Again,  a  serious  strain  upon  the  air-cells  is  induced  by 
strong  expiratoiy  efforts  made  when  the  glottis  is  closed,  as  when  the 
patient  is  preparing  to  cough.  Such  efforts  drive  the  air  into  the  j^arts  of 
the  lungs  which  are  the  least  supported,  and  dilate  to  excess  the  alveoli 
in  these  situations.  In  pertussis,  especially,  where  the  child  strives  with 
all  his  might  to  repress  the  cough,  the  strain  is  often  very  severe  and  long 
continued.  Marked  emphysema  of  the  apices  and  anterior  margins  of  the 
lungs  fliay  be  excited  by  this  means,  and  if  the  over-stretched  walls  of  the 
air-cells  have  been  injured  by  the  distention,  the  lesion  may  be  a  per- 
manent one.  Usually  the  alveoli  return  to  their  normal  size  when  their 
walls  cease  to  be  distended.  It  is  only  when  the  dilatation  has  been 
earned  to  an  extreme  degree,  so  as  to  impair  the  elasticity  of  the  alveolar 
parietes,  that  the  distention  continues  as  a  permanent  condition. 

Besides  the  diseases  which  have  been  mentioned,  any  complaint  of 
which  cough  is  a  symptom  may  give  rise  to  emphysema  ;  as  phthisis, 
where  the  alveoli  at  the  bases  often  become  distended  ;  pleui-isy,  where  the 
air-vesicles  of  the  sound  lung  are  often  temporarily  over-dilated  ;  also 
stridulous  laryngitis,  if  prolonged,  and  membranous  croup.     In  advanced 


492  DISEASE   IN   CHILDEEF. 

rickets,  wliere  there  is  marked  grooving  of  tlie  sides  of  tlie  chest,  the 

sternum  is  forced  forwards  at  each  inspii-ation,  and  the  anterior  borders  of 
the  lungs  become  over-distended  with  aii'.  The  mechanism  of  this  form 
of  emphysema  is  refen-ed  to  elsewhere  (see  page  134).  The  tendency  to 
perjDetuation  of  the  vesicular  dilatation  appeal's  to  be  influenced  by  the 
scrofulous  diathesis.  It  may  be  that  in  that  constitutional  condition  the 
elasticity  of  the  alveolar  walls  is  more  readily  impaii'ed  ;  or  it  may  be  that 
the  susceptibility  to  catarrh  of  the  jDulmonary  membrane  and  other  mucous 
ti-acts,  inse^Darable  from  the  strumous  habit,  induces  a  more  fi-equent  and 
persistent  strain  upon  the  aii'-cells.  In  any  case  the  subjects  of  chronic 
emjDhysema  in  early  life  ai'e  usually  found  to  be  well-marked  examples  of 
the  scrofulous  diathesis. 

Pulmonary  emjDhysema  may  be  found  at  aU  ages.  It  is  not  uncommon 
even  in  infants  recently  boi-n.  Thus,  out  of  thrrty-seven  cases  collected 
by  Her'sieux,  nineteen  occun-ed  in  infants  under  twenty  days  old,  and  of 
these  one  had  hved  no  longer  than  two  days.  So,  in  a  chUcl  who  died  of 
tetanus  imder  my  care  in  the  East  London  Children's  Hospital,  aged  fifty 
hours,  the  lungs  after  death  were  found  to  be  emphysematous  along  the 
anterior  margins,  and  also  in  spots  over  the  surface.  There  were  some 
sohd  patches  of  unexpanded  tissue  in  each  lower  lobe. 

3Iorbid  Anatomy. — Pulmonaiy  emphysema  may  be  of  the  interlobular 
or  vesicular  variety. 

In  interlobular  emi^hysema  the  aii'  occupies  the  connective  tissue  lying 
between  the  lobules  and  under  the  pleura.  "When  infiltrated  into  the 
tissue  between  the  lobules,  au  collects  in  small  bubbles  like  little  beads. 
■WTien  in  the  sub-pleural  tissue,  it  forms  blebs  of  varying  size — sometimes 
isolated,  when  they  may  reach  the  size  of  a  small  nut  ;  sometimes  arranged 
in  lines,  when  they  are  rarely  larger  than  an  ear  of  wheat.  Their  shape  is 
elongated  or  spherical.  T\Tien  thus  extravasated  into  the  pulmonary  con- 
nective tissue,  the  aii-  has  been  known  to  make  its  way  into  the  anterior 
or  posterior  mediastinum  and  thence  into  the  sub-cutaneous  tissue  of  the 
face  and  neck.  Thus,  in  a  case  published  in  1834:  by  Dr.  Buxl  Herapath — 
a  child  eighteen  months  old  who  had  died  of  bronchitis  secondary  to 
whooping-cough — air  was  found  to  have  escaped  from  one  of  the  lobules 
seated  at  the  root  of  the  right  lung  into  the  anterior  mediastinum.  Start- 
ing from  this  point  the  air,  -without  entering  the  pleura,  had  escaped  along 
the  sub-pleural  connective  tissue  and  formed  numerous  emphysematous 
swelhngs  on  the  lung.  It  had  distended  the  areolar  tissue  of  the  anterior 
mediastinum,  and  j^assing  upwards  had  infiltrated  into  the  cellular  tissue 
of  the  neck,  beneath  the  deeper  cer-\ical  fascia  and  the  subcutaneous 
tissue  of  the  neck  and  chest.  A  similar  case,  in  a  child  four  months  old, 
has  been  recorded  by  Dr.  Pepper,  of  Philadelphia.  In  rare  cases  pneurho- 
thorax  has  been  produced  by  ruptiue  of  the  pleui-a  and  escape  of  au' 
into  the  pleural  cavity. 

Interlobular  emphysema  is  almost  always  produced  by  rupture  of  an 
air-vesicle  dui'ing  a  violent  fit  of  coughing.  It  may,  however,  be  the  result 
of  injuiy  from  without. 

In  vesicular  emphysema  the  apices  and  anterior  borders  of  the  lungs  are 
the  parts  commonly  affected.  These  portions  are  dull  white  in  colour, 
dry,  and  bloodless. "  They  convey  to  the  finger  a  pecuHar  soft  sensation, 
which  Hervieux  has  compared  to  that  noticed  when  pressing  a  piece  of 
wadding  covered  with  satin.  Close  inspection  in  a  good  light  shows  a 
multitude  of  little,  bright,  transparent  points  the  size  of  a  pin's  head. 
Sometimes  rather  larger  projections  are  visible,  and  these  are  often  angular. 


EMPHYSEMA — SYMPTOMS.  493 

When  the  chest  is  opened  in  these  cases  the  lungs  remain  distended,  and 
their  anterior  borders  are  usually  in  contact  so  as  to  hide  the  greater  por- 
tion of  the  cardiac  surface. 

Symptoms. — Interlobular  emphysema,  unless  the  air  spread  through  the 
mediastinum  to  the  sub-cutaneous  tissue  of  the  neck  and  chest,  gives  rise 
to  no  symptoms.  Its  existence  is  only  discovered  on  post-mortem  examina- 
tion of  the  body. 

Even  in  the  vesicular  variety  the  Hmited  amount  of  emphysema  which 
is  found  when  the  disease  is  acute,  as  in  cases  of  catarrhal  pneumonia,  or 
acute  bronchitis  with  collapse,  gives  little  evidence  of  its  presence.  Our 
knowledge  of  the  morbid  anatomy  of  such  cases  enables  us  to  infer  its  ex- 
istence, but  the  occurrence  of  abnormal  dilatation  of  the  air-cells  givq^  rise 
to  no  additional  symptoms,  and  produces  no  characteristic  modification  of 
the  physical  signs. 

It  is  in  the  chronic  form  of  the  disease  that  we  are  able  positively  to 
determine  the  existence  of  over-distention  of  the  pulmonary  alveoli.  In  a 
pronounced  case  of  emphysema  the  symptoms  and  physical  signs  are  those 
familiar  to  us  as  a  consequence  of  a  similar  condition  in  the  adult.  Such 
children,  as  has  been  already  remarked,  almost  always  present  the  char- 
acteristic features  of  the  strumous  constitution.  The  patient  is  usually 
short  for  his  age  and  of  sturdy  build.  His  head  is  rather  large,  his  neck 
short  with  prominent  jugular  veins,  and  his  face  pallid  with  a  blueish  tint 
round  the  mouth  and  eyes.  The  chest  is  flattened  laterally  at  the  base, 
and  the  lower  part  of  the  sternum  is  somewhat  projecting.  Consequently, 
its  antero-posterior  diameter  is  increased.  The  intercostal  spaces  are 
obliterated,  and  in  rare  cases  slight  bulging  may  be  noticed  above  the 
clavicles.  Sometimes  the  back  is  a  little  rounded,  but  I  have  never  noticed 
the  stoop  of  the  shoulders,  which  is  such  a  marked  feature  in  the  adult, 
unless  the  emphysema  were  combined  with  a  persistent  chronic  bronchitis. 
The  heart  is  pushed  down  so  as  to  be  felt  beating  in  the  ej)igastrium,  and 
the  liver  and  spleen  are  often  appreciably  displaced. 

When  a  deep  breath  is  taken  the  chest-walls  rise  and  the  shoulders  are 
elevated  ;  but  there  is  little  expansion  of  the  upper  part  of  the  thorax,  and 
the  constriction  at  the  base  is  exaggerated.  On  percussion,  general  hyper- 
resonance  is  found  in  the  front  of  the  chest  and  the  cardiac  area  of  dulness 
is  lessened.  With  the  stethoscope  we  find  that  the  breath  sounds  are  loud 
and  wheezing  above,  weak  although  very  harsh  below,  and  more  or  less 
sonoro-sibilant  rhonchus  is  heard  at  various  parts  of  the  chest. 

The  symptoms  vary  according  to  the  condition  of  the  pulmonary  mucous 
membrane  ;  for,  with  such  a  state  of  lung,  the  child  is  excessively  sus- 
ceptible to  fresh  catarrh.  At  his  best  his  breathing  is  habitually  short  and 
oppressed,  but  he  coughs  little  and  his  appetite  and  spirits  may  be  good. 
It  is  when  a  new  catarrh  comes  on  that  his  troubles  begin.  When  this  ac- 
cident happens,  the  breathing  at  once  becomes  difficult  and  wheezing,  and 
he  is  subject  to  attacks  of  dyspnoea  which  appear  sometimes  to  be  of  the 
nature  of  asthmatic  seizures.  There  is,  however,  another  cause  for  these 
attacks.  In  scrofulous  subjects  the  bronchial  glands  of  the  mediastina  and 
lungs  are  apt  to  enlarge  as  a  result  of  pulmonary  irritation ;  and  these  by 
their  pressure  upon  the  vagus,  or  directly  upon  the  air-tubes,  may  produce 
serious  impediment  to  the  entrance  of  air.  The  child's  cough  is  husky 
and  often  occurs  in  paroxysms.  He  cannot  lie  down  in  his  bed,  and  is 
much  troubled  at  night  by  cough  and  dyspncea.  If  these  symptoms  con- 
tinue, the  patient  passes  into  the  condition  which  is  described  elsewhere 
under  the  name  of  chronic  bronchitis,  and  a  case  is  there  narrated  in  which 


494  DISEASE  IN   CHILDREN. 

dironic  pulmonary  catarrh  was  associated  with  permanent  emphysema  of 
the  lungs. 

In  cases  where  the  attacks  of  catarrh  are  only  occasional  and  pass  com- 
pletely away,  the  habitual  state  of  the  child  is  not  unsatisfactory ;  but  he 
is  liable  at  any  moment  to  be  laid  by  under  the  influence  of  a  fresh  chill. 

I  may  cite  as  a  good  example  of  chronic  pulmonary  emphysema  the 
case  of  a  little  boy,  aged  three  years,  stout  and  thick-set,  with  large  ends 
to  his  bones.  The  child  only  finished  cutting  his  teeth  at  the  age  of  two 
years  and  nine  months,  and  was  no  doubt  slightly  rickety.  He  was  said  to 
have  been  wheezing  off  and  on  for  eighteen  months.  Ten  months  pre- 
viously he  had  been  iU  for  a  month  with  a  severe  attack  of  bronchitis,  and 
had  %ince  that  time  been  a  constant  sufferer  from  wheezing  and  short- 
ness of  breath.  Li  this  boy  the  upper  part  of  the  chest  was  full  and 
rounded,  and  there  was  some  considerable  constriction  at  the  base.  The 
heart's  apex  could  be  seen  and  felt  in  the  epigastrium  and  between  that 
point  and  the  left  nipple.  The  percussion  note  was  drum-like  all  over  the 
front  of  the  chest,  and  much  whistling  and  snoring  rhonchus  was  heard 
over  both  lungs.     The  heart-sounds  were  healthy. 

Another  httle  boy,  aged  two  years  and  nine  months,  was  said  to  have 
had  a  cough  all  his  life,  although  it  was  better  in  the  summer  than  the 
winter,  and  might  even  cease  altogether  for  about  six  weeks  in  the  warmest 
weather.  The  child  was  twelve  months  old  before  he  cut  his  first  tooth, 
and  did  not  walk  until  the  end  of  his  second  year.  The  ends  of  his  long 
bones  were  full ;  but'  his  limbs  were  straight,  and  he  was  not  a  marked 
specimen  of  rickets.  The  breathing  was  not  much  oppressed  ;  the  cough 
was  hoarse,  and  the  voice  husky.  He  was  not  subject  to  attacks  of  dis- 
tressing dyspnoea,  and  was  said  never  to  have  lost  his  voice.  This  little 
lad's  chest  was  perceptibly  retracted  in  the  infra-mammary  regions,  and 
the  lower  part  of  the  breast-bone  projected.  The  spine  was  straight  and 
the  back  rather  flattened  between  the  scapulae.  At  each  breath  there  was 
a  slight  sinking  of  the  epigastrium.  On  percussion  there  was  general 
hjTDer-resonance  of  the  fi-ont  of  the  chest,  especially  along  the  sternum. 
Some  sibilant  and  large  bubbling  rhonchi  were  heard  at  each  base  behind. 

In  such  cases  as  the  above  the  emphysema  is  no  doubt  kept  up  by  the 
repeated  attacks  of  pulmonary  catarrh.  It  is  possible  that  if  by  residence 
in  a  suitable  cHmate  such  intercurrent  attacks  could  be  prevented,  the 
emphysema  might  subside  and  the  lungs  return  to  a  normal  condition  ; 
but  upon  this  point  I  cannot  speak  with  certainty. 

It  is  not  often  in  the  child  that  serious  secondary  effects,  such  as 
passive  congestion  of  the  liver  and  kidneys,  dilated  hypertrophy  of  the  right 
heart,  oedema,  etc.,  are  noticed,  although  in  some  cases  I  have  thought 
that  the  right  ventricle  was  larger  than  natural.  The  danger  of  the  disease 
consists  principally  in  the  repeated  attacks  of  bronchitis  from  which  these 
patients  almost  invariably  suffer,  and  in  the  tendencj^  of  such  attacks,  if 
not  immediately  fatal,  to  run  a  chronic  course.  Usually,  sooner  or  later, 
the  life  of  the  patient  is  brought  prematm^ely  to  a  close  by  this  means. 

Diagnosis.— In  the  acute  form  of  emphysema  there  are  no  symptoms 
sufficiently  distinctive  to  indicate  with  certainty  the  presence  of  the  lesion. 
This,  however,  is  of  little  consequence,  for  no  special  treatment  is  required. 
In  the  large  majority  of  cases  the  dilated  air-ceUs  return  to  their  natural 
size  when  the  cause  or  causes  which  have  induced  the  distention  are  no 
longer  in  operation. 

In  chronic  emphysema  the  chest  distended  in  the  upper  regions  and 
hyper-resonant  on  percussion,  the  diminished  area  of  cardiac  duhiess,  the 


EMPHYSEMA — DIAGNOSIS — PROGNOSIS — TREATMENT.  495 

pulsation  at  the  epigastrium,  tlie  displacement  of  the  liver  and  spleen  (if 
j)resent),  and  the  wheezing  breath-sounds  are  sufficiently  characteristic  of 
the  lesion. 

Prognosis. — In  chronic  emphysema  the  prognosis  is  not  favourable  ; 
for  although  the  disease  in  itself  is  Httle  hurtful  to  Hfe,  the  accompanying 
tendency  to  catarrh  is  a  serious  danger  to  the  patient.  If  the  child  be 
found  to  suffer  from  repeated  attacks  of  bronchitis,  and  in  the  intervals 
to  be  wheezy  and  scant  of  breath,  we  can  never  feel  satisfied  with  his 
condition  or  at  ease  with  regard  to  his  future  prospects. 

In  cases  of  interlobrdar  emphysema,  where  this  has  led  to  infiltration 
of  air  into  the  subcutaneous  tissue  of  the  neck  and  chest,  the  prognosis 
depends  chiefly  upon  the  disease,  in  the  course  of  which  the  complication 
has  arisen.  The  joresence  of  subcutaneous  emphysema  is  probably  of 
little  consequence,  for  the  infiltrated  air  usually  becomes  absorbed  very 
quickly. 

Treatment. — In  cases  where  acute  emphysema  is  suspected  no  special 
treatment  is  required.  So,  also,  in  interlobular  emphysema,  where  this 
has  made  itself  evident  by  the  passage  of  air  into  the  subcutaneous  tissue, 
no  special  measures  are  needed  to  hasten  the  absorption  of  the  infiltrated 
gases.     They  may  safely  be  left  to  disperse  at  leisure. 

In  chronic  emphysema  any  existing  bronchitis  should  receive  immediate 
attention,  and  the  treatment  must  be  conducted  upon  the  principles 
described  elsewhere  (see  Bronchitis).  In  the  attacks  of  acute  dyspnoea 
emetics  are  very  useful ;  and  ipecacuanha  wine  or  the  turpeth  mineral, 
each  of  which  produces  free  secretion  of  mucus,  are  to  be  preferred  for 
this  purpose.  A  teaspoonful  of  the  former,  or  three  or  four  grains  of  the 
latter  in  syrup,  may  be  given  every  fifteen  minutes  until  an  effect  is  pro- 
duced. If  the  attacks  continue,  the  feet  should  be  soaked  in  a  hot  mustard 
foot-bath,  mustard  poultices  should  be  applied  to  the  chest  and  back, 
and  a  draught  containing  ether  and  the  tincture  of  lobeUa  may  be  given 
every  hour.  Children  bear  lobelia  well.  Ten  drops  of  the  ethereal  tinct- 
ure may  be  given  to  a  child  of  two  years  old  every  hour  or  half  hour 
without  any  danger.  In  very  severe  cases  the  fumes  of  Himrod's  powder 
may  be  inhaled.  When  the  bronchitis  has  subsided  iron  should  be  given. 
A  good  form  for  its  administration  is  the  tartarate  of  iron  vnth  iodide  of 
potassium.  The  combination  makes  a  perfectly  clear  mixture  with  dis- 
tilled water.     It  may  be  sweetened  with  glycerine. 

The  food  of  the  child  should  be  nutritious  and  digestible.  The  diet 
should  be  regulated  upon  the  principles  ah-eady  laid  down  for  the  treat- 
ment of  scrofula.  In  fact,  emphysematous  subjects,  who,  as  has  been  said, 
are  very  often  of  the  strumous  habit,  require  in  all  points  such  general 
treatment  as  is  recommended  elsewhere  for  children  suffering  from  the 
scrofulous  cachexia.  The  most  important  point  in  the  treatment  of  pul- 
monary emphysema  lies  in  the  adoption  of  means  for  the  prevention 
of  catarrh.  "With  this  object  we  should  urge  upon  the  child's  parents  the 
necessity  of  removing  the  patient  to  an  equable  climate  where  he  can  live 
an  out-door  life  without  danger  of  chill.  It  is  only  by  keeping  the  lungs 
free  from  catarrh  that  we  can  hope  to  promote  a  return  of  the  air-cells  to 
their  normal  condition. 


CHAPTER  XI. 

GANGRENE  OF  THE  LUNG. 

Gangeene  of  the  lung  is  not  a  common  disease  of  childhood.  If  the  num- 
ber of  recorded  cases  be  a  fair  measure  of  the  relative  frequency  of  the 
lesion,  this  form  of  illness  would  appear  to  be  much  more  often  met  with 
in  adult  life  than  at  an  earlier  age.  A  contrary  opinion  has,  however,  pre- 
vailed, chiefly  on  the  authority  of  E.  Boudet,  who  in  the  space  of  five 
months  met  with  five  cases  of  pulmonary  gangrene  in  the  child.  This 
experience  is,  however,  too  exceptional  to  furnish  a  satisfactory  base  for 
statistical  calculation. 

The  extent  of  tissue  which  undergoes  the  gangrenous  change  is  variable. 
The  lesion  may  occupy  only  a  hmited  patch  in  one  of  the  lobes  (circum- 
scribed gangrene),  or  may  involve  the  whole  of  the  lobe,  or  even  of  the 
lung  (diffused  gangrene). 

Causation. — Pulmonary  gangrene  may  be  the  consequence  of  a  general 
condition  affecting  the  whole  body,  or  may  arise  in  constitutionally  healthy 
subjects  from  some  local  cause  which  interferes  with  the  circulation  of  the 
blood  in  the  lung. 

In  the  first  case,  a  disposition  to  spontaneous  mortification  of  tissue  is 
manifested  as  a  result  of  the  eruptive  fevers,  especially  measles,  and  other 
dejoressing  diseases  which  cause  great  prostration  of  nervous  power  and 
lower  the  nutrition  of  the  whole  body.  The  gangrene  is  usually  of  the 
diffused  variety,  and  the  lung  is  often  not  the  only  organ  which  suffers 
from  the  morbid  tendency.  There  may  be  also  gangrene  of  the  gums,  the 
cheeks,  the  pharynx,  and  in  female  children  of  the  vagina,  and  these  com- 
monly precede  in  point  of  time  any  manifestation  of  a  similar  affection  of 
the  pulmonary  organs. 

Of  the  local  causes  which  interfere  with  the  circulation  through  the 
lungs  the  most  common  in  children  is  probably  the  presence  of  a  foreign 
body  in  the  air-passages.  The  irritation  of  the  intruding  substance  sets 
up  a  form  of  pneumonia  which  may  run  rapidly  into  gangrene.  Of  the  few 
examples  of  the  lesion  which  have  come  under  my  own  care  one  was  a  case 
of  this  kind.  It  is  narrated  shortly  in  another  chapter  (see  page  529).  In 
cases  where  lobar  pneumonia  ends  in  mortification  of  the  lung  the  gan- 
grenous lesion  cannot  be  looked  upon  as  a  natural  consequence  of  the  pul- 
monary inflammation.  Indeed,  the  inflammatoiy  disease  is  often  not  a 
true  croupous  pneumonia,  but  an  acute  hepatisation  of  the  lung  resulting 
from  the  presence  in  the  organ  of  some  local  ii-ritant.  Thus,  a  variety  of 
pulmonary  inflammation  with  Avhich  gangrene  is  often  associated  is  that 
due  to  emboh  swept  into  the  pulmonary  cn-ciilation  from  an  ante-mortem 
clot  formed  in  the  right  side  of  the  heart.  The  irritation  of  these  emboh 
causes  complete  stasis  in  neighbouring  vessels,  and  sets  up  putrefaction 
and  gangrene  in  the  lung  tissue  around.  Bouillard  states  that  this  ac- 
cident may  happen  in  cases  of  true  croupous  pneumonia  and  determine  the 


GAISraEElSrE  of  the  lung — MOEBID  anatomy — SYMPTOMS.      497 

gangrenous  change  ;  indeed,  according  to  this  observer,  a  peculiar  ten- 
dency to  the  formation  of  svich  coagiila  is  a  common  feature  of  the  pneu- 
monic disease.  But  even  if  this  be  the  case,  the  mortification  of  tissue  is 
induced  by  something  superadded  to  the  original  lesion,  and  is  not  to  be 
regarded  as  an  ordinary  incident  of  the  croupous  form  of  pulmonary 
inflammation. 

The  retention  of  decomposing  secretions  in  dilated  bronchi  and  cavities  in 
the  lung  is  another  local  cause  of  the  gangrenous  lesion  in  the  child.  It  may 
arise  in  the  course  of  phthisis,  or  at  the  end  of  an  attack  of  acute  catarrhal 
pneumonia.  So,  also,  extensive  hemorrhage  into  the  lung,  if  it  undergo 
putrefaction,  is  said  to  be  a  cause  of  gangrenous  changes  in  the  surround- 
ing tissue.  No  doubt  in  all  these  cases  a  debilitated  or  cachectic  state  of 
the  system  favours  the  occurrence  of  pulmonary  gangrene  ;  but  mortifica- 
tion of  the  lung  may  arise  in  children  of  sound  constitution  who  are  well 
nourished,  and  whose  sanitary  surroundings  have  been  to  all  appearance 
satisfactory. 

Morhid  Anatomy. — The  commonest  form  in  which  gangrene  of  the  lung 
is  met  with  in  the  child  is  that  of  a  patch  of  mortification  situated  in  the 
centre  of  a  lobe  and  surrounded  by  gray  hepatised  tissue.  The  gan- 
grenous patch  consists  of  a  pulpy  detritus,  yeUowish-grey,  dark  green,  or 
slate  grey  in  coloiir,  and  intolerably  offensive  in  its  smell.  It  gradually 
breaks  down  and  leaves  a  cavity  with  disintegrated  gangrenous  shreds  ad- 
hering to  its  walls.  This  is  the  circumscribed  variety  in  which  the  num- 
ber of  sphacelated  masses  may  be  one  or  more.  In  some  cases  the  diseased 
area  is  very  small,  and  the  lesion  consists  merely  in  greenish  streaks  of 
gangrenous  odour  and  semi-liquid  consistence  in  the  centre  of  a  broncho- 
pneumonic  nodule.  In  other  instances  we  find  patches  of  catarrhal 
pneumonia  enclosing  small  gangrenous  abscesses  of  variable  number,  com- 
municating here  and  there  with  a  bronchus. 

In  the  diffused  variety  the  gangrenous  change  involves  more  or  less  of 
the  whole  lobe.  Thus,  in  a  case  recorded  by  Dr.  Hayes,  after  the  death 
of  the  patient — a  boy  of  seven  years  of  age — the  lower  half  of  the  inferior 
lobe  of  the  right  lung  was  in  a  state  of  grey  hepatisation.  Its  tissue  was 
very  friable,  and  drops  of  pus  exuded  from  it  on  pressure.  The  remainder 
of  the  lung  was  of  a  dark  purplish  colour.  Its  tissue  broke  down  on  the 
slightest  pressure  and  gave  forth  an  unbearable  stench.  The  centre  of 
the  middle  lobe  was  occupied  by  an  irregular  cavity,  about  the  size  of  a 
large  walnut,  filled  with  putrid  matter. 

In  the  circumscribed  form  the  seat  of  the  lesion  is  usually  the  lower 
lobe  or  the  periphery  of  the  organ.  In  the  latter  case  the  pleura  may 
be  inflamed  or  may  participate  in  the  sjDhacelating  process.  In  my 
own  case,  related  elsewhere,  not  only  was  the  whole  of  the  left  lung  in  a. 
state  of  gangrene,  but  adhesions  had  foi-med  between  the  adjacent  layers 
of  the  pleui-a  at  the  posterior  surface.  Moreover,  the  chest-wall  had  been 
perforated  in  the  eighth  intercostal  space,  and  a  communication  had  formed 
between  the  disintegrated  lung  and  an  extensive  abscess  which  lay  outside 
the  wall  of  the  chest. 

If  adhesion  of  the  jDleura  does  not  occur,  pneumothorax  may  arise  from 
rupture  of  the  lung  into  the  pleural  cavity. 

In  many  cases  the  bronchial  glands  are  enlarged  and  cheesy.  In  two 
of  Rilliet  and  Barthez'  cases  they  were  gangrenous. 

Symptoms. — The  symptoms  of  the  disease  are  often  very  indefinite. 
They  may  consist  only  of  general  drooping,  disinclination  to  exertion, 
pallor  and  wasting,  with  slight  cough  and  obscure  pains  about  the  chest. 
32 


498  DISEASE  IN   CHILDEElSr. 

The  physical  signs  may  be  also  indefinite,  consisting  merely  of  slight  dul- 
ness  at  a  certain  part  of  the  chest,  with  feebleness  of  breath-sound.  After 
a  time  the  child  dies  without  any  more  characteristic  symptoms  having 
been  developed,  and  the  autopsy  discovers  a  patch  of  gangrene  in  the  lung. 
In  almost  all  the  cases  observed  by  Eilliet  and  Barthez,  these  ex]3erienced 
physicians  failed  to  detect  the  natui-e  of  the  illness  during  the  life  of  the 
patient. 

In  more  pronounced  cases  the  disease  may  begin  gradually  or  sud- 
denly. In  the  first  case  the  child  is  noticed  to  be  faihng.  His  appetite 
is  poor,  he  looks  pale,  and  his  flesh  feels  flabby.  Soon  he  comj)lains  of 
pains  in  the  chest,  coughs  occasionally,  and  sits  by  the  fire  if  the  weather 
is  chiUy,  refusing  to  play,  and  objecting  to  any  exertion.  He  is  thirsty 
and  sleeps  restlessly  at  night,  being  often  disturbed  in  his  sleep  by 
cough. 

The  sudden  onset  may  be  announced  by  headache  and  sickness,  a 
feeling  of  chilliness,  or  even  a  rigor.  The  child  is  feverish,  with  a  dry  skin  ; 
is  very  restless  and  anxious,  and  the  piolse  is  quickened.  Perhaps  there 
may  be  pain  in  the  side  and  a  dry  cough. 

When  the  symptoms  are  fully  developed  the  patient  is  j)ale  and  weakly 
looking,  with  a  haggard  expression  of  countenance,  and  dull,  sunken  eyes. 
The  tongue  is  foul,  and  appetite  is  almost  completely  lost.  The  bowels 
are  seldom  relaxed  ;  sometimes  there  is  marked  constipation.  There  is 
often  great  restlessness,  so  that  the  child  is  in  constant  uneasy  movement 
in  his  bed.  The  jDulse  is  feeble  and  frequent,  130-150  ;  the  respirations 
30-40.  The  temjoerature  is  high,  and  may  reach  103°  or  104°  in  the  even- 
ing, usually  faihng  in  the  morning  to  100°  or  101°.  The  cough  is  frequent 
and  loose.  It  is  often  excited  by  movement  and  may  be  accompanied  by 
pains  in  the  back  or  side.  Usually  there  is  expectoration  even  in  young 
children,  for  the  sputum  is  too  offensive  to  be  swallowed.  It  exhales  a 
sickening  odour,  and  is  frothy  and  reddish-brown  in  colour.  On  standing 
it  deposits  a  reddish-brown,  shreddy  sediment,  containing  greyish  putrid 
granules,  in  which  Leyden  and  Jaffe  have  discovered  bacteria  and  a  special 
fungus — the  leptothrix  pulmonaris.  In  quantity  the  expectoration  varies 
from  time  to  time,  being  sometimes  copious,  sometimes  scanty  and  more 
tenacious.  Occasionally  the  fetid  odour  ceases  to  be  noticed,  but  it  usually 
quickly  returns.  A  similar  odour  is  perceived  in  the  breath  of  the  patient, 
especially  during  cough.  As  in  the  case  of  the  expectoration,  its  offensive- 
ness  occasionally  ceases  for  a  time.  The  cough  may  be  so  harassing  and 
frequent  as  almost  entirely  to  prevent  sleep  ;  and  the  consequent  exhaus- 
tion, combined  with  the  unwillingness  of  the  child  to  take  adequate 
nourishment,  adds  greatly  to  his  weakness. 

In  most  pubhshed  cases  great  variation  has  been  noticed  in  the  in- 
tensity of  the  symptoms.  Sometimes  the  pulse  is  excessively  frequent 
and  feeble,  the  eyes  sunken  and  lustreless,  the  restlessness  extreme,  the 
cough  distressing,  and  the  face  earthy  or  lead-coloui'ed.  The  breathing 
also  may  be  laboui'ed  and  difficult.  Thus,  in  a  case  recorded  by  Dr. 
Sturges  there  were  attacks  of  violent  dyspnoea  in  which  the  face  looked 
pinched  and  blue,  the  expression  was  terrified,  the  body  was  covered 
with  a  clammy  sweat,  and  no  pulse  could  be  felt  at  the  wrist.  At  other 
times  the  symptoms  are  less  distressing,  the  face  looks  brighter,  the  cough 
is  quieter,  the  pulse  fuller,  and  the  manner  more  composed.  The  patient, 
however,  from  day  to  day  grows  evidently  weaker,  and  in  the  large  majority 
of  cases  sinks  after  a  further  period  of  suffering.  Sometimes  death  is 
preceded  by  one  or  more  attacks  of  haemoptysis.     In  a  case  reported  by 


GANGRENE   OF   THE   LUNG SYMPTOMS — DIAGNOSIS.  499 

Dr.  Hayes,  the  child,  on  the  afternoon  before  his  death,  after  a  fit  of 
coughing,  spat  up  half  a  pint  of  red,  frothy  blood  ;  and  the  haemoptysis 
was  repeated  in  the  evening  shortly  before  he  died. 

In  some  cases  gangrene  of  the  gums  or  cheek  has  been  observed  ; 
and  if  the  signs  from  the  lungs  are  not  marked,  the  fetor  of  breath  may 
be  attributed  to  the  presence  of  these  lesions. 

The  duration  of  the  illness  in  cases  v^hich  terminate  in  death  is  never 
very  prolonged.  Dr.  L.  Atkins,  who  has  collected  thirty-one  cases  of  the 
affection,  states  that  it  varies  between  two  days  and  twenty.  The  child 
usually  dies  from  asthenia.  The  complexion  grows  more  and  more  livid, 
the  pulse  weaker  and  more  rapid,  and  death  may  be  preceded  by  a  gush 
of  blood  from  the  mouth  or  by  rupture  of  the  lung  and  the  formation  of 
,  pneumo-thorax. 

In  the  rare  cases  in  which  recovery  has  been  recorded,  the  fetor  of  the 
breath  disappeared  at  the  end  of  a  fortnight  or  three  weeks ;  but  con- 
valescence was  very  slow. 

The  physical  signs  in  cases  of  pulmonary  gangrene  are  not  distinctive 
of  the  lesion.  At  first  the  signs  are  usually  those  of  bronchitis.  Percus- 
sion of  the  chest  discovers  no  dulness,  and  with  the  stethoscope  we  find 
merely  large  bubbling  rhonchus  pervading  the  lung  on  both  sides.  After 
a  few  days  a  limited  area  of  dulness  is  detected  at  some  part  of  the  chest — 
usually  the  posterior  base  ;  the  breath-sound  becomes  bronchial,  and  the 
rales  are  drier  and  more  crepitating  in  character.  The  dulness  usually 
extends  its  area  and  may  pass  to  the  front  of  the  chest.  If  eventually  a 
cavity  form,  it  may  give  no  evidence  of  its  presence  unless  its  situation  be 
near  the  periphery.  In  that  case  the  breathing  may  become  bronchial, 
blowing,  or  cavernous,  and  the  rhonchus  larger  and  more  distinctly  gurg- 
ling. In  the  case  of  a  large  cavity  amphoric  respiration  with  metallic 
tinlde  may  be  discovered  at  some  point  in  the  dull  area. 

In  a  case  which  was  under  the  care  of  my  colleague  Dr.  Donkin,  in  the 
East  London  Children's  Hospital — a  microcej)halic  idiot,  between  two  and 
three  years  old,  who  was  admitted  for  rigidity  and  paralysis  of  joints,  with 
partial  loss  of  consciousness — the  breath  a  few  days  before  death  was  noticed 
to  have  an  insupportably  offensive  odour.  The  child  began  to  cough  slight- 
ly, and  the  pulse  and  respiration  were  greatly  hurried.  On  examination  of 
the  chest  dulness  was  discovered  at  the  left  base,  passing  round  from  the 
back  to  the  front,  being  most  intense  beneath  the  left  axilla.  Much  large 
bubbling  rhonchus  was  heard  all  over  both  sides,  especially  the  left. 
The  child  grew  rajDidly  worse,  the  face  became  much  pinched,  and 
petechise  appeared  upon  the  abdomen.  The  temperature,  which  had 
been  always  high,  rose  to  108°  shortly  before  death.  An  autopsy  revealed 
two  small  embolic  infarctions  in  the  left  lung.  The  lower  lobe  was  com- 
pletely solidified,  and  contained  a  cavity  the  size  of  a  hen's  egg.  This 
excavation  was  partially  lined  with  a  membrane,  and  held  much  stinking 
fluid  and  detritus.  The  right  lung  was  merely  congested  with  patches  of 
collapse. 

In  this  case  the  high  temperature  noted  before  death  was  probably 
due  more  to  the  condition  of  the  brain  than  to  that  of  the  kmg.  The 
cavity  seems  to  have  been  the  consequence  of  breaking  down  of  an  inflam- 
matory consolidation  set  up  by  a  metastatic  infarction,  the  gangrenous 
nature  of  the  process  being  determined  by  the  low  nervous  power  of  the 
patient. 

Diagnosis. — On  account  of  the  uncertain  character  of  the  symptoms 
and  physical  signs  which  present  no  definite  features  by  which  the  disease 


500  DISEASE  IN   CHILDREN. 

can  be  recognised,  we  are  forced  to  rely  solely  upon  a  gangrenous  odour 
from  the  breath  and  expectoration  for  evidence  of  the  nature  of  the 
lesion.  Without  this  symptom  there  is  reaUy  nothing  in  the  condition 
of  the  child  to  suggest  that  the  inflammatory  process  has  gone  on  to 
mortification  of  tissue  ;  for  a  cachectic  appearance,  great  feebleness,  a  hag- 
gard look,  constant  restlessness,  and  varying  intensity  of  symptoms  are 
common  to  many  forms  of  illness.  If  the  characteristic  fetor  of  breath 
be  present  alone,  it  may  be  the  consequence  of  other  conditions.  In 
gangrenous  stomatitis  and  gangrene  of  the  pharynx  the  same  phenom- 
enon may  be  observed  ;  and  in  many  cases  of  ciiThosis  of  the  lung, 
when  secretion  is  retained  and  becomes  decomposed  in  the  dilated  tubes, 
the  odoiu'  of  the  breath  may  be  exceedingly  offensive.  In  the  latter  dis- 
ease, although  the  breath  and  expectoration  may  be  very  offensive  without 
obvious  gangrene  being  present,  shreds  of  sphacelated  tissue  are,  no  doubt, 
present  in  the  matters  discharged  from  the  lung.  If  gangrene  of  the  lung 
coincide  with  the  same  condition  of  the  mouth  the  unpleasant  odour  is 
usually  attributed  to  the  lesion  which  is  within  reach  of  the  eye,  and  the 
pulmonary  gangrene  may  not  improbably  pass  unrecognised.  The  ap- 
pearance of  offensive  expectoration,  however,  at  once  du'ects  attention  to 
the  lung,  and  if  hsemoptj^sis  occiu',  the  blood  giving  out  the  same  unbear- 
able odour,  doubt  is  no  longer  possible. 

In  infants  and  the  youngest  children  expectoration  is  sometimes  absent, 
but  a  gangrenous  odour  from  the  breath  is  seldom  wanting.  Fetor  of  the 
breath  in  such  cases  is  the  more  characteristic,  as  fibroid  induration  of 
the  lung  is  very  rare  below  the  age  of  six  years,  and  gangrene  of  the  mouth 
is  not  often  met  with  during  the  first  two  yeai'S  of  life. 

Prognosis. — Recovery  is  so  exceptional  a  termination  of  the  disease  that 
in  any  particular  case  the  patient's  chance  of  escape  is  very  small.  Varia- 
tions in  the  severity  of  the  symptoms  are  a  common  feature  of  the  illness, 
and  we  must  not  allow  our  hopes  to  rise  too  high  merely  because  we  find 
the  child  looking  brighter  and  more  composed,  and  notice  that  the  fetid 
odour  from  the  breath  is  no  longer  to  be  perceived.  Such  a  favourable 
change  is  too  often  only  a  temporary  improvement,  to  be  followed,  perhaps  in 
a  few  hoiu-s,  by  a  retui-n  of  all  the  worst  symptoms.  If,  however,  the  char- 
acteristic odour  is  not  reproduced,  and  we  find  that  the  prdse  becomes 
fuller  and  stronger,  and  the  cough  less  distressing  ;  that  the  tongue  begins 
to  clean  and  the  appetite  to  retru'n,  we  may  venture  to  hope  that  the  favour- 
able change  may  be  maintained.  According  to  Kohts,  when  the  gangTene 
results  from  the  presence  of  a  foreign  body  in  the  lung  the  prospect  is 
less  desperate  than  in  other  cases,  but  this  can  only  be  if  the  iz-ritating 
substance  is  expelled. 

Treatment. — In  the  treatment  of  this  distressing  disease  we  must  do 
our  best  to  support  the  strength  of  the  child  and  make  energetic  employ- 
ment of  disinfecting  and  stimulating  inhalations. 

The  chamber  should,  if  possible,  be  large,  and  must  be  kept  thoroughly 
ventilated.  It  should  be  continually  disinfected  by  spraying  with  carbolic 
acid  or  Condy's  fluid,  and  pans  of  either  disinfectant  should  stand  about 
the  room. 

The  child  should  be  made  frequently  to  inhale  vapours  or  sprays  im- 
pregnated with  oil  of  tui'pentine  {Vi[  xx.-xxx.)  to  the  pint  of  boiling  water, 
or  with  creasote  or  carbohc  acid  (TTl,  xx.-xxx.  to  the  pint).  Glycerine  of 
cai'bolic  acid  may  be  also  given  internally,  in  one  or  two  drop  doses,  accord- 
ing to  the  age  of  the  child  ;  and  Traube  recommends  the  salicylate  of  soda 
or  the  acetate  of  lead.     The  sulpho-carbolates  are  said  to  be  of  service  in 


GANGKENE   OF  THE  LUNG — PROGNOSIS — TEEATMENT.         501 

removing  fetor,  if  given  freely.  The  sulpho-earbolate  of  soda  may  be  given 
to  a  child  of  four  years  old  in  doses  of  four  grains  every  six  hours.  Buc- 
quoy  recommends  the  tincture  of  eucalyptus  for  the  same  purpose,  and 
states  that  the  remedy  not  only  reduces  the  offensive  odour  of  the  breath 
and  sputum,  but  relieves  the  violence  of  the  cough.  A  child  of  four  years 
old  may  take  five  or  six  drops  three  times  a  day. 

Quinine  and  the  mineral  acids  are  preferred  by  some ;  and  it  is  impor- 
tant that  the  former,  if  employed,  should  be  given  in  full  doses.  For  each 
dose  the  quantity  may  be  calculated  at  one  grain  and  a  half  for  each  year  of 
the  child's  age  ;  and  this  may  be  given  three  or  four  times  in  the  twenty- 
four  hours.  Ammonia  and  bark  have  also  their  advocates.  The  bowels 
must  be  kept  regular.  If  they  are  confined  a  dose  of  castor-oil  will  usually 
relieve  the  constipation. 

Alcoholic  stimulants  are  always  required.  For  an  infant  white  wine 
whey,  for  an  older  child  the  brandy-and-egg  mixture  should  be  given  at 
frequent  intervals. 

With  regard  to  diet :  an  infant  should  be  restricted  to  milk  diluted  with 
barley-water  and  guarded  with  a  few  drops  of  the  saccharated  solution  of 
lime  (twenty  drops  to  the  teacupful).  An  older  child  can  take  milk,  strong 
beef-tea,  pounded  meat,  eggs,  etc.,  in  quantities  regulated  according  to  his 
age  and  powers  of  digestion.  In  this,  as  in  all  other  cases  where  the  de- 
bility is  great,  we  must  remember  that  the  digestion  shares  in  the  general 
weakness ;  and  must  be  careful  not  to  overload  the  stomach  or  fill  the 
blood  with  unassimilable  nutriment  in  our  anxiety  to  sustain  the  strength 
and  obviate  death  from  asthenia. 


CHAPTER  XII. 

PULMONARY   PHTHISIS. 

PuLMONAET  phthisis  is  a  common  disease  in  the  child.  The  term  signifies 
ulceration  of  the  pulmonary  tissue.  The  aifection  is  therefore  perfectly 
distinct  from  acute  tuberculosis.  The  latter  is  a  general  disease  in  which 
the  lungs,  if  they  are  involved  at  all,  are  affected  in  common  with  most 
other  organs  of  the  body,  and  if  they  undergo  disintegration,  break  down 
as  a  consequence  of  inflammatory  changes  due  only  indirectly  to  the 
presence  of  the  grey  granulation.  Pulmonary  phthisis,  even  when  the  con- 
sequence of  a  general  dyscrasia,  is  especially  a  lung  disease,  which  if  it  run 
its  course  unchecked  passes  on  necessarily  to  softening  and  excavation. 

Phthisis  may  be  acute  or  chronic.  The  acute  form  is  not  uncommon  in 
young  subjects,  and  consists  in  rapid  hepatisation  and  caseous  infiltration 
of  the  lungs,  with  equally  rapid  softening  and  disintegration.  This  form 
of  the  disease  is  to  be  distinguished  from  acute  pulmonary  tuberculosis^ 
although  it  may  be  combined  with  it. 

Chronic  phthisis  is  seen  in  two  principal  forms,  viz.,  chronic  tubercular 
phthisis  and  catarrhal  or  pneumonic  phthisis.  These  varieties  differ  mark- 
edly in  then'  mode  of  origin,  their  course,  and  often  in  their  termination, 
and  are,  no  doubt,  the  consequence  of  very  distinct  j)athological  conditions. 

Causation.  —Most  cases  of  pulmonary  phthisis  are  dependent  upon  a 
general  predisposition,  which  may  be  hereditary  or  acquired.  The  child 
may  be  born  into  a  consumptive  family  and  thus  inherit  a  constitutional 
delicacy  which  renders  him  especiall}'  sensitive  to  moi'bific  influences.  On 
the  other  hand,  although  without  any  family  tendency  to  this  form  of  ill- 
ness, the  patient  may  yet,  through  the  agency  of  special  disease,  aided  per- 
haps by  insanitary  surroundings,  acquire  a  pulmonary  weakness  which 
sooner  or  later,  under  suitable  conditions,  developes  phthisical  changes  in 
the  lung. 

The  inherited  disease  may  consist  of  either  form  of  phthisis ;  and 
either  variety  may  be  acquired  by  a  child  in  whose  family  no  tendency  to 
consumption  can  be  discovered.  Even  chronic  tubercular  phthisis,  al- 
though in  the  majority  of  cases  no  doubt  the  consequence  of  an  inherited 
predisposition,  may  be  excited  by  infective  agency  through  the  presence  of 
softening  cheesy  matter  at  some  part  of  the  body.  A  special  pulmonary 
delicacy  is  often  the  consequence  of  whooping-cough  and  measles.  These 
diseases  are  very  hable  to  be  comphcated  by  catarrhal  pneumonia,  and  it 
often  happens  that  after  convalescence  the  absorption  of  the  consohdatiug 
material  is  incomplete.  Consequently  a  caseous  lump  is  left  at  some  part 
of  the  lung,  which  after  remaining  inactive  for  a  shorter  or  longer  period 
begins  at  length  to  soften  and  set  up  irritation  in  its  neighbourhood.  But 
even  if  perfect  absorption  of  the  consolidating  material  take  place,  a  certain 
susceptibility  may  be  left  after  the  subsidence  of  the  inflammation,  so  that 
the  child  becomes  attacked  again  and  again  by  obstinate  catarrhs.     These 


PULMONARY   PHTHISIS — CAUSATIOjS".  503 

catarrhs  in  favourable  subjects  are  apt  to  lead  to  cellular  infiltration  of  the 
bronchial  walls  and  gradual  invasion  of  the  alveoK.  In  this  way  a  catarrhal 
or  pneumonic  phthisis  is  eventually  developed. 

In  children  of  scrofulous  tendencies  there  is  very  commonly  a  pulmo- 
nary weakness.  The  child  is  very  subject  to  catarrhs,  and  he  has  also  the 
proneness  insej^arable  from  his  strumous  constitution  to  rapid  prolifera- 
tion and  caseation  of  cellular  elements.  In  such  a  subject  a  catarrhal 
phthisis  is  readily  set  up.  So,  also,  in  subjects  especially  prone  to  tuber- 
cular formation  the  lung  in-itation  may  induce  this  variety  of  pathological 
change.  In  the  present  day,  owing  to  the  discovery  by  Koch  of  the  tuber- 
cle bacillus,  there  is  a  tendency  to  look  upon  all  forms  of  phthisis  as  due  to 
infective  agency.  According  to  this  view,  the  various  pathological  condi- 
tions would  be  all  tubercular,  as  the  bacillus  appears  in  most  cases  to  be  ■ 
discoverable  either  in  the  sputum  or  the  pulmonary  tissue  of  the  part 
affected.  The  question,  however,  is  as  yet  far  from  settled  ;  and  looking  at 
the  wide  differences  in  the  clinical  characters  of  the  several  forms  of  ptd- 
monary  phthisis,  it  seems  desirable  to  consider  these  diseases  from  a  clinical 
rather  than  from  an  anatomical  point  of  view. 

The  causes  which  tend  to  originate  a  pulmonary  weakness  or  encourage 
a  natural  delicacy  of  lung  ate  all  those  which  in  any  way  help  to  lower 
nutrition  and  depress  the  natural  vigour  of  the  body.  In  childhood — a 
period  of  hfe  in  which  nutrition  is  only  maintained  at  a  healthy  standard 
by  the  continual  influx  of  nutritive  material — any  interference  with  the 
digestive  or  assimilative  processes  has  an  exceptional  influence  in  diminish- 
ing resisting  power.  It  is  for  this  reason,  probably,  that  in  unwholesome 
conditions  of  living  shght  febrile  attacks,  such  as  are  incidental  to  many 
of  the  less  serious  ailments  of  early  life,  may  start  an  enfeebling  process 
which  ultimately  determines  phthisical  changes.  In  this  way  unsuitable 
food  and  close  rooms,  a  damp  residence,  mental  depression  from  unkind 
treatment,  over-exercise  of  the  immature  brain,  and  any  other  like  agency 
may  have  an  influence  in  exciting  the  mischief  in  the  lung. 

Certain  diseases  have  an  undoubted  tendency  to  be  followed  by 
phthisis.  On  this  account  measles  and  whooping-cough  are  justly  dreaded 
for  the  injurious  influence  they  are  known  to  exercise  upon  scrofulous  and 
weakly  subjects.  These  affections  not  only  encourage  a  special  lung 
weakness,  but  also  by  promoting  enlargement  and  caseation  of  the  lym- 
phatic glands,  may  set  up  a  focus  of  infection  by  which,  through  the 
medium  of  the  blood-vessels  or  lymphatics,  secondary  inflammatory  pro- 
cesses of  a  more  or  less  acute  character  may  be  excited  in  the  lung. 
Scarlatina,  too,  is  sometimes  a  cause  of  phthisis,  acting  by  similar  means  ; 
empyema  may  induce  the  pulmonary  mischief  through  absorption  of 
infective  material  from  the  pleura ;  and  the  disease  not  uncommonly 
arises  in  children  who  suffer  from  scrofulous  joints  and  old-standing 
caries  of  bone.  The  influence  of  catarrhal  pneumonia  in  inducing  the 
disease  has  been  already  referred  to. 

Since  the  discovery  of  the  bacillus  the  question  of  the  infectiveness  of 
phthisis  from  person  to  person  has  again  assumed  considerable  prominence. 
The  presence  of  bacilli  has  been  discovered  in  the  air  expu-ed  by  con- 
sumptive patients  ;  and  if  this  micx-ophyte  be  indeea  the  agent  by  which 
the  infection  is  conveyed,  it  would  seem  to  follow  as  a  logical  conclusion 
that  the  disease  must  be  continually  communicated  by  this  means. 
Whether,  however,  it  be  that  a  predisposition  of  rare  intensity  is  required 
for  the  ready  reception  and  development  of  the  bacillus,  or  that  the  im- 
portance of  this  organism  as  an  infecting  agent  has  been  overestimated. 


504  DISEASE  IlSr   CHILDBEN. 

tlie  fact  remains  that  the  disease  is  practically  not  communicable  by  this 
means. 

3IorUd  Anatomy. — In  all  cases  of  jDulmonary  phtliisis  the  lungs  after 
death  are  found  to  be  more  or  less  consolidated  by  a  cheesy-looking  sub- 
stance Trhich  is  in  various  stages  of  softening  and  disorganization. 
"\'\Tiether  the  disease  has  begun  by  a  chronic  process  of  tubercuhsation, 
or  has  originated  in  a  catarrhal  pneumonia  and  epithehal  accumulation  in 
the  alveoli,  the  degeneration  of  the  morbid  material  gives  rise  to  caseous 
solidification  of  very  similar  character.  Even  when  the  primary  patho- 
logical change  consists  in  a  chronic  formation  of  gTey  tubercle  in  the 
lung  tissue,  a  secondary  catan'hal  pneumonia  is  usually  set  up  sooner  or 
later  ;  and  the  resulting  caseous  infiltration  materially  contributes  to  the 
enlargement  of  the  area  of  solidification.  Again,  -when  the  form  of 
j)hthisis  is  originally  catarrhal,  softening  of  the  cheesy  material  which 
infiltrates  the  lung  may  be  a  source  of  infection.  By  this  means  a  second- 
ary formation  of  mihaiy  tubercle  is  excited,  at  first  in  the  immediate 
neighbourhood  of  the  aft'ected  region,  afterwards  more  generally  over  both 
the  lungs.  Consequently,  in  most  cases,  the  pathological  changes  are  not 
simple,  but  tend  to  complicate  one  another,  so  that  the  lung  is  at  the  same 
time  the  seat  of  different  morbid  processes.  '  We  often  find  grey  or  yellow 
gi'anulations  combined  with  masses  of  yellow  infiltration  of  various  extent. 
In  these  masses  the  tissue  is  soft  and  fiiable,  and  on  section  is  found  to 
be  drpsh,  of  a  straw  or  grey  coloiii-,  and  streaked  or  spotted  with  black 
]Digment.  The  surface  is  commonly  marked  with  intersecting  hues  which 
indicate  the  position  of  the  interlobular  septa.  At  the  borders  of  the  con- 
solidated region  is  usually  a  zone  of  reddish-grey  glutinous  infiltration. 
Often  many  of  these  caseous  masses  are  seen  scattered  over  the  lung, 
the  jDulmonary  tissue  between  them  being  oedematous  or  congested,  and 
partially  collapsed. 

If  the  phthisis  has  reached  an  advanced  stage,  cavities  from  breaking 
down  of  the  consolidating  material  are  usually  found.  Cavities  are  not 
uncommon  in  the  young  subject,  and  are  probably  met  with  less  frequently 
in  the  child  than  in  the  adult,  only  because  the  disease  in  early  Hfe  often 
proves  fatal  from  a  secondary  tuberculosis  or  other  exhausting  complica- 
tion before  the  stage  of  excavation  has  been  arrived  at.  When  softening 
begins,  it  always  occurs  first  in  the  centre  of  the  caseous  mass.  The  dead 
shrunken  cells  and  molecular  debris  lying  around  them  are  loosened  by 
the  imbibition  of  watery  fluid,  and  the  cheesy  material  is  converted  into 
a  soft  purulent  pulp.  The  wall  of  the  bronchus,  which  Hes  in  the  centre 
of  the  nodule,  then  becomes  perforated,  and  the  cheesy  matter  is  coughed 
up,  leaving  a  ragged  excavation.  The  softening  may  attack  the  cheesy 
masses  generally  through  the  lung,  as  happens  in  the  more  acute  form  of 
the  disease  ;  or  may  begin  in  those  situated  in  the  upper  j)art-  of  the  lung, 
and  thus  pass  gradtially  from  apex  to  base.  The  expectorated  matter  in 
these  cases  contains  particles  of  elastic  tissue  and  shi'unken  cells,  and 
often  under  the  microscope  exhibits  bacilli  in  large  quantities. 

In  cases  where  the  disease  consists  principally  of  the  grey  and  yellow 
miliary  nodules,  these  bodies  are  seen  grouped  in  clusters  and  more  or 
less  closely  aggregated.  They  are  more  numerous  towards  the  apex  ;  but 
sometimes  the  whole  of  both  lungs  may  be  seen  to  be  stuffed  with  them  ; 
and  in  some  parts,  in  addition,  there  may  be  softening  cheesy  masses, 
more  or  less  disintegrated.  In  most  cases  the  lungs  are  also  found  to  be 
the  seat  of  increased  fibrosis,  and  some  dilatation  of  the  smaller  air-tubes 
can  be  perceived. 


PULMONAEY   PHTHISIS — MORBID   ANATOMY — ACUTE.         505 

The  real  tubercular  phthisis  attacks  both  lungs  simultaneously.  The 
catarrhal  form  begins  in  one  lung,  and  it  is  not  until  signs  of  softening  are 
noticed  that  the  ojDposite  lung  becomes  affected.  This  softening  of  the 
cheesy  matter  in  the  affected  lung  is  often  a  signal  for  a  more  general 
diffusion  of  the  disease.  The  apex  of  the  opposite  lung  is  attacked,  and 
caseation  and  softening  occur  in  the  glands  of  Peyer's  patches  and  in  the 
solitary  follicles  in  the  neighbourhood  of  the  ilio-csecal  valye,  giving  rise 
eventually  to  ulceration  of  the  bowels. 

On  microscopical  examination  of  the  lungs,  the  seat  of  pulmonary 
phthisis,  various  histological  changes  are  discovered.  According  to  Dr.  T. 
Henry  Green,  these  are  mainly  of  four  kinds  :  1st,  a  fiUing  of  the  pul- 
monary vesicles  with  fibrinous  exudation  and  leucocytes  ;  2d,  an  accumula- 
tion of  large  epithelial  cells  within  the  alveoli ;  3d,  an  infiltration  and 
thickening  of  the  walls  of  the  air-vesicles,  and  often  also  of  the  terminal 
bronchi  with  small  cells  ;  4th,  an  increase  of  the  interlobular  connective 
tissue.  These  various  changes  occur  in  varying  degrees  in  different  cases, 
but  all  of  them  are  said  to  be  present  in  the  majority  of  instance^,  although 
in  very  different  j^roportions.     ' 

In  a  practical  treatise  it  is  unnecessary  to  enter  minutely  into  the 
various  pathological  changes  which  combine  to  make  up  a  case  of  pul- 
monary phthisis  ;  and  the  reader  is  referred  to  the  standard  works  on 
pathological  anatomy  for  fuller  information  upon  this  subject.  The  pre- 
ceding sketch  is  necessarily  brief  and  imperfect  ;  but  some  reference  to 
the  conditions  which  give  rise  to  the  signs  and  symptoms  about  to  be 
enumerated  was  indispensable. 

The  acate  and  chronic  forms  of  pulmonary  phthisis  will  be  described 
separately. 

ACUTE  PHTHISIS. 

Acute  phthisis,  or  "  galloping  consumption,"  is  not  uncommon  in  early 
life.  The  term  is  sometimes  used  to  include  cases  of  acute  pulmonary 
tuberculosis.  It  is,  however,  more  properly  restricted  to  cases  of  rapid 
catarrhal  pneumonia  where,  as  a  result  of  an  acute  inflammatory  process, 
the  air-cells  become  stuffed  with  epithelial  elements  which  undergo  rapid 
caseation,  and  the  solidified  tissue  quickly  breaks  down  into  cavities.  The 
consolidation  is  at  first  lobular  and  is  generally  diffused  over  the  lungs. 
Softening  takes  place  pretty  equally  in  all  parts  at  the  same  time,  so  that 
the  lung  becomes  destroyed  by  sinuous  and  burrowing  cavities  separated 
by  reddened  and  oedematous  tissue  ;  much  purulent  matter  is  formed,  and 
the  lining  membrane  of  the  air-passages  is  excessively  red.  In  this  form 
mihary  tubercle  may  occur  as  a  complication,  but  its  appearance  is  com- 
paratively rare,  for  the  disease  is  essentially  pneumonic  in  its  nature.  ' 

Acute  phthisis  generally  occurs  in  a  child  who  has  been  reduced  in 
health  by  previous  illness  or  bad  hygienic  conditions,  and  is  sometimes 
seen  to  attack  one  already  the  subject  of  a  chronic  consolidation  which  had 
given  rise  to  but  few  symptoms.  The  age  of  patients  so  affected  is  usually 
five  or  six  years  and  upwards. 

Symptoms. — The  general  features  of  the  illness  are  those  of  an  acute 
attack  of  pneumonia  combined  with  very  great  severity  of  the  general 
symptoms.  At  first  the  child  usually  complains  of  a  pain  in  the  side. 
This  may  come  on  quite  suddenly  during  some  sUght  muscular  exercise. 
Thus,  in  a  httle  girl  under  my  care,  the  child  first  complained  while  she  was 
helping  her  mother  to  make  a  bed.  The  pain  may  subside  after  a  time, 
or  be  complained  of  occasionally  all  through  the  illness.   Cough  comes  on  at 


506  DISEASE   IN   CHILDEElSr. 

the  same  time  with  the  pain,  and  the  child  is  noticed  to  be  very  feverish  at 
night.  In  older  children  the  cough  is  usually  accompanied  by  expectora- 
tion. The  sputum  is  at  first  whitish  and  aerated,  but  as  the  lungs  begin 
to  break  down  it  becomes  yellow  or  greenish  and  nummulated,  and  is 
found  to  contain  large  quantities  of  yellow  elastic  tissue.  The  number  of 
bacilli  found  in  the  sputum  is  not,  however,  always  very  great.  In  some 
cases  under  my  care  these  organisms  were  found  in  much  less  quantities 
than  in  cases  of  phthisis  which  ran  a  more  chronic  course. 

Dyspnoea  is  always  an  early  symptom  ;  the  appetite  is  very  poor,  thirst 
is  great,  the  tong-ue  is  furred,  the  bowels  are  relaxed  or  confined,  and  the 
child  wastes  with  extreme  rapidity.  In  some  cases  swelling  of  the  abdomen 
is  noticed,  and  the  liver  may  be  found  to  be  enlarged  from  fatty  infiltration. 

The  fever  is  often  very  high.  It  is  not  uncommon  to  find  that  the  tem- 
perature rises  to  104°  or  105°  at  night,  sinking  to  100°  or  101°  in  the 
morning.  It  soon  begins  to  be  accompanied  by  copious  sweats,  and  the 
night-clothes  may  be  drenched  by  the  profuseness  of  the  secretion. 

Examination  of  the  chest  discovers  principally  the  signs  of  broncho- 
pneumonia,. Dulness  is  noticed,  usually  beginning- at  the  upper  part  of  the 
lung.  At  the  onset  this  may  be  limited  to  one  side  of  the  chest,  but  the 
opposite  lung  becomes  very  quickly  affected.  That  first  attacked,  how- 
ever, generally  maintains  its  precedence  and  keeps  in  advance  of  its  fellow 
throughout  the  course  of  the  disease.  The  diminution  of  resonance  in- 
volves more  and  more  of  the  area  of  the  lung,  and  is  accompanied  by 
bronchial  or  blowing  breathing  which  may  be  more  or  less  covered  by  a 
copious,  coarse,  subcrepitant  rhonchus.  This  rale  is  usually  heard  over 
the  whole  extent  of  both  inspiration  and  expiration,  and  is  very  large  and 
metallic  in  quality.  In  spots  here  and  there  cavernous  respiration  may  be 
heard  after  a  time  ;  and  the  rhonchus  in  such  places  is  larger  and  more 
ringing  than  elsewhere.  If  a  cavity  of  some  size  form,  the  breath-sounds 
may  be  amphoric.  Vocal  resonance  is  usually  stronger  than  natural,  and 
may  be  bronchophonic  in  places. 

The  above  are  the  physical  signs  in  a  typical  case  of  the  disease  ;  but  it 
must  be  confessed  that  in  many  cases,  especially  in  the  younger  children, 
cavities  may  form  in  the  lung  without  any  sign,  of  their  existence  beiug 
noticed  on  examination  of  the  chest.  In  such  cases  the  signs  are  chiefly 
those  of  catarrhal  pneumonia  ;  but  the  dulness  begins  at  the  upper  part  of 
the  chest  instead  of  the  lower,  and  the  rhonchus  is  usually  larger  and  more 
ringing  and  metalHc  than  in  an  ordinary  case  of  broncho-pneumonia.  The 
child  in  all  cases  looks  excessively  haggard  and  ill.  The  wasting  is  very 
rapid  ;  in  a  surj)risingiy  short  time  the  temples  and  cheeks  get  hollow,  and 
the  flesh  seems  to  fall  away  from  the  body.  Often  more  or  less  general 
"oedema  is  noticed,  although  an  examination  of  the  urine  may  discover  no 
trace  of  albumen. 

A  httle  gM,  aged  thirteen  years,  was  said  to  have  been  healthy  until  the 
age  of  six  years,  when  she  had  an  attack  of  measles  followed  very  shortly 
by  scarlatina.  Enlarged  glands  formed  in  her  neck  soon  afterwards,  and 
some  of  these  suppurated.  Since  that  time  the  girl  had  been  delicate,  but 
had  never  coughed  until  ten  months  before  coming  under  observation. 
For  four  months  her  cough  had  been  very  distressing,  and  she  had  suffered 
much  from  pain  in  the  side.  She  had  been  very  feverish,  had  sweated 
profusely  at  night,  and  had  wasted  rapidly. 

The  girl  was  much  emaciated  and  very  weak.  She  had  a  distressed, 
haggard  expression.  The  cervical  glands  were  enlarged,  and  her  neck  bore 
many  scars  resulting  from  former  suppurations.     On  examination  of  the 


ACUTE   PULMOlSrAKY   PHTHISIS — DIAGlSrOSIS — PEOGlSrOSIS.      507 

chest  the  clavicles  were  seen  to  be  very  prominent  from  retraction  of  the 
apices  of  the  lungs.  There  was  much  diminution  of  resonance  over  the 
whole  of  the  right  side  and  at  the  upper  third  on  the  left ;  and  much  coarse, 
metaUic,  bubbling  rhonchus  was  heard  over  the  whole  of  both  sides.  The 
respiration  was  cavernous  towards  each  apex,  and  bronchial  below.  The 
liver  was  enlarged,  reaching  nearly  to  the  navel. 

The  girl  complained  grea,tly  of  dyspnoea  and  sweated  freely  at  night. 
Her  cough  was  troublesome,  and  she  expectorated  nummular  sputa.  She 
said  the  sputa  had  never  contained  blood.  Her  face  and  feet  were  cedem- 
atous,  and  her  urine  contained  albumen.     There  was  no  diarrhoea. 

During  the  first  few  days  the  girl's  temperature  was  101°  at  night,  sink- 
ing to  the  normal  level  in  the  morning.  It  then  became  subnormal  both 
morning  and  evening,  and  the  patient  died  on  the  twelfth  day  after  admis- 
sion into  the  hospital.  On  inspection  of  the  body  cavities  were  found  at 
the  upper  part  of  each  lung,  and  other  small  collections  of  purulent  matter 
were  scattered  over  both  organs.  The  pulmonary  tissue  generally  was  red, 
and  easily  broke  down  under  the  finger.  At  the  base  of  the  right  lung  a 
marked  increase  in  the  fibrous  tissue  was  noticed,  and  the  bronchial  tubes 
in  that  situation  were  somewhat  dilated.  No  grey  or  yeUow  tubercles 
were  to  be  seen.  The  pleural  surfaces  were  firmly  adherent.  The  kidneys 
appeared  to  be  healthy. 

Death  is  preceded  in  these  cases  by  great  prostration,  restlessness,  and 
inability  to  sleep,  complete  anorexia,  a  glossy  eroded  tongue,  and  sordes 
upon  the  teeth  and  hps.  The  duration  of  the  illness  is  comparatively 
short,  and  death  usually  takes  place  at  the  end  of  five  or  six  months. 

Diagnosis. — The  disease  with  which  acute  phthisis  is  most  liable  to  be 
confounded  is  acute  pulmonary  tuberculosis.  In  the  beginning,  however, 
the  affection  may  be  mistaken  for  croupous  pneumonia.  The  sudden 
onset,  accompanied  by  pain  in  the  side,  cough,  and  high  fever,  presents 
sometimes  a  close  resemblance  to  an  oi'dinary  case  of  inflammation  of  the 
lung.  Still,  the  temperature  does  not  maintain  the  same  httle  varying 
elevation  in  acute  phthisis  as  in  croupous  pneumonia,  and  the  course  of 
the  illness  in  the  two  cases  is  very  dififerent.  Instead  of  the  sudden  crisis 
which  occurs  in  pneumonia  about  the  end  of  the  first  week,  the  symptoms 
persist  and  grow  more  and  more  severe,  the  signs  of  consolidation  con- 
tinue to  extend  themselves,  the  opposite  lung  is  quickly  afiiected,  and 
very  soon  elastic  tissue,  and  perhaps  bacilli,  can  be  discovered  in  the 
si^utum. 

From  acute  pulmonary  tuberculosis  the  disease  is  distinguished  by  its 
more  abrupt  onset,  the  early  signs  of  pulmonary  consolidation,  and  the 
absence  of  indications  pointing  to  the  implication  of  other  cavities  of  the 
body.  Comparatively  few  cases  of  pulmonary  tuberculosis  in  the  child 
terminate  without  some  signs  of  intracranial  mischief  ;  but  when  acute 
phthisis  is  uncomplicated  by  tuberculosis  these  are  absent.  The  two 
diseases  are,  however,  sometimes  present  together.  The  existence  of  the 
tubercular  malady  is  then  made  evident  sooner  or  later  by  the  onset  of 
convulsions,  squinting,  rigidity  of  joints,  and  other  symptoms  pointing  to 
meningitis. 

Prognosis. — Acute  phthisis  is  a  very  fatal  disease,  and  the  prognosis  is 
consequently  very  unfavourable.  The  patients  do  not  invariably  die,  but 
instances  of  recovery  are  exceptionally  rare.  In  any  case  the  best  we  can 
hope  for  is  a  remission  in  the  acuteness  of  the  symptoms.  Sometimes  the 
disease,  its  first  force  expended,  loses  a  part  of  its  energy  and  becomes 
more  measured  and  tranquil  in  its  course.     It  may  even  settle  down  into 


508  DISEASE  IN   CHILDEEN. 

an  ordinary  case  of  chronic  plithisis.  It  is  impossible  in  any  individual 
instance  to  anticipate  such  a  result  ;  but  a  diminution  in  the  pyrexia,  if 
combined  with  an  improvement  in  the  appetite  and  a  brighter  expression 
in  the  face  of  the  child,  is  a  sign  of  good  omen.  A  decrease  in  the  fever, 
if  unaccompanied  by  other  signs  of  improvement,  so  far  from  being  a 
favourable  symptom,  is  one  to  be  regarded  with  great  anxiety  ;  and  if, 
under  such  circumstances,  the  temperature  fall  to  a  subnormal  level,  it 
may  be  an  indication  that  the  end  is  not  far  off. 

The  treatment  of  these  cases  will  be  considered  afterwards. 


CHRONIC  PULMONARY  PHTHISIS. 

The  two  principal  forms  in  which  chronic  pulmonary  phthisis  usually 
presents  itself  in  the  child  have  well-marked  and  very  distinctive  char- 
acters. Chronic  catarrhal  or  pneumonic  phthisis,  which  begins  as  a  slowly 
forming  consolidation  of  one  lung,  or  succeeds  to  an  attack  of  acute  catar- 
rhal pneumonia  from  imperfect  absorption  of  the  solidifying  material,  has 
at  first  the  characters  of  a  local  disease.  It  is  accompanied  by  certain  signs 
and  symptoms  which  indicate  the  existence  of  irritation  within  the  lung  ; 
but  as  a  rule  the  general  health  is  comparatively  little  interfered  with, 
nutrition  is  fairly  performed,  and  the  appearance  of  the  child  gives  little 
evidence  of  serious  pulmonary  mischief.  It  is  only  when  softening  is  set 
up  at  the  seat  of  consolidation,  and  infection  of  the  system  follows  with 
secondary  deposits  in  the  opposite  lung  and  other  parts  of  the  body,  that 
signs  occur  indicating  that  the  patient  is  suffering  from  a  general  disease. 
Even  when  these  general  symptoms  arise,  they  remain  for  a  long  time 
insignificant  as  compared  with  the  signs  of  extensive  disease  discovered  on 
examination  of  the  chest.  On  the  other  hand,  chronic  tubercular  jDhthisis 
has  completely  different  characters.  From  the  first — indeed,  before  any 
signs  of  pulmonary  irritation  have  been  noticed — there  is  some  fever  and 
wasting,  showing  general  distress  of  the  system  ;  and  throughout  the 
whole  coui'se  of  the  illness  the  general  symptoms  continue  severe  out  of 
all  proportion  to  the  actual  extent  of  lung  mischief  discoverable  by  the 
stethoscope.  Therefore,  whatever  opinions  may  be  held  with  regard  to 
the  pathology  of  these  two  varieties,  they  still  remain  two  distinct  clinical 
tyj)es  marked  out  from  one  another  by  very  separate  and  distinctive 
features. 

Symptoms. — The  peculiarities  in  the  size  and  shape  of  the  chest  often 
met  with  in  children  of  consumptive  tendencies  are  elsewhere  referred  to 
(see  page  399).  It  may,  however,  be  remarked  that  although  small  limgs 
and  a  narrow  elongated  chest  are  often  found  associated  with  an  inherited 
pulmonary  weakness,  phthisis  is  not  confined  to  such  subjects.  We  shall 
never  be  justified  in  excluding  pulmonary  phthisis  because  the  child's 
shoulders  are  broad  and  his  chest  well  proportioned.  In  the  pneumonic 
form  of  phthisis  the  eye  often  detects  nothing  to  raise  a  suspicion  of  pul- 
monary mischief.  It  is  the  tubercular  variety  which  is  most  constantly 
combined  with  narrow  sloping  shoulders  and  flattened  ribs. 

In  both  varieties  of  phthisis  we  find  local  sj^mptoms  significant  of  pul- 
monary distress,  and  general  symptoms  arising  from  irritation  of  the 
system  and  impaired  nutrition.  The  severity  of  the  case  is  usually  very 
fairly  indicated  by  the  degree  in  which  the  latter  predominate  over  the 
former. 

In  chronic  pneumonic  phthisis  the  first  sign  of  the  disease  is  usually 


CHRONIC   PULMOISTARY   PHTHISIS — SYMPTOMS.  509 

cough.  The  patient  may  have  lately  passed  through  an  attack  of  acute 
catarrhal  pneumonia,  or  may  have  suffered  from  neglected  pulmonary 
catarrh  with  gradual  implication  of  the  alveoli  at  one  apex.  In  the  first 
case  the  child  recovers  his  strength  but  slowly.  He  continues  to  cough, 
often  violently  ;  and  is  more  or  less  feverish  at  night.  After  a  time,  how- 
ever, the  fever  subsides,  and  the  child  regains  flesh  and  a  certain  propor- 
tion of  his  strength  ;  but  he  still  looks  pale  and  has  a  frequent  hacking 
cough.  In  the  second  case  the  disease  creeps  on  insensibly,  and  at  last  it  is 
noticed  that  the  child  coughs,  and  is  pale  and  easily  tired.  However  the 
disease  may  have  originated,  the  symptoms  are  insignificant  as  long  as  the 
unabsorbed  deposit  in  the  lung  is  undergoing  no  active  change.  A  child 
with  an  unabsorbed  mass  of  caseous  matter  in  his  lung  may  be  plump, 
active,  and  cheerful  ;  but  he  is  usually  rather  pale,  may  complain  of  pains 
in  the  limbs,  and  is  apt  to  cough  a  little  in  the  morning  or  in  the  day 
after  exertion.  On  examination  of  the  chest  at  this  period  we  find  slight 
dulness  with  some  little  increase  of  resistance  at  the  apex  or  any  other 
part  of  the  chest  on  one  side.  If  at  the  apex,  the  dulness  is  best  detected 
at  the  supra-spinous  fossa.  The  breathing  is  bronchial  and  some  coarse 
clicks  are  heard  with  inspiration.  The  resonance  of  the  voice  is  also  in- 
creased. Children  with  the  lung  in  this  condition  are  very  susceptible  tc 
chills  ;  and  if  first  seen  when  the  lungs  are  the  seat  of  a  fresh  catarrh, 
general  bubbling  may  be  heard  all  over  the  diseased  side  ;  and  also,  but 
to  a  less  extent,  over  the  opposite  lung.  When  this  happens  it  is  difficult 
to  form  a  correct  opinion  as  to  the  actual  amount  of  disease  present  in  the 
chest ;  and  it  is  well  to  correct  our  first  impressions  by  the  results  of  a 
subsequent  examination. 

At  this  stage  of  the  illness,  before  softening  has  begun,  absorption  is 
still  possible,  and  sometimes  occurs  in  young  subjects  many  months  after 
the  first  symptoms  have  been  noticed. 

When  softening  begins  the  general  symptoms  become  more  pro- 
nounced. There  is  fever,  the  evening  temperature  rising  to  102°  or  103°; 
there  is  marked  pallor,  although  the  cheeks  become  flushed  towards 
night  ;  and  the  expression  is  distressed.  Often  the  child  sweats  towards 
the  morning.  These  symptoms  indicate  an  infection  of  the  system  by 
absorption  from  the  softening  area.  The  disease  from  being  local  is 
becoming  general ;  and  the  consequences  are  quickly  seen  in  the  inter- 
ference with  nutrition  which  never  fails  to  ensue.  The  child  begins  to 
lose  flesh  and  strength  ;  his  spiiits  fail ;  his  appetite  and  digestion  become 
poor,  and  he  shows  all  the  synjptoms  of  suffering.  The  course  of  the 
disease  is  almost  always  unequal.  Every  now  and  again  an  improvement 
is  seen  to  take  place.  By  careful  nursing  and  treatment  the  fever  dimin- 
ishes or  subsides  ;  the  nutrition  improves  ;  and  flesh  and  strength  are 
regained.  It  is  not  uncommon  to  see  a  child  fairly  plump  and  to  all 
appearance  in  tolerable  health,  who  yet  has  a  cavity  in  one  lung  and  signs 
of  consolidation  at  the  opposite  apex. 

During  this  stage  pains  are  often  complained  of  in  the  shoulder  of  the 
affected  side.  They  come  and  go,  and  seldom  continue  for  long  together. 
The  respirations  are  usually  more  hurried  than  in  health,  but  when  the 
child  is  quiet  are  not  necessai-ily  much  exaggerated.  The  increased  fre- 
quency of  breathing  is  a  cause  of  no  inconvenience  to  the  patient,  and 
unless  after  exertion  does  not  give  rise  to  a  feeling  of  dyspnoea.  The 
cough  is  frequent  and  fairly  loose.  If  expectoration  occur,  the  sputum 
consists  of  yellowish  or  greenish  muco-purulent  matter  which  under  the 
microscope  is  found  to  contain  fragments  of  yellow  elastic  tissue  and 


510  DISEASE   IN   CHILDREN. 

often  bacilli,  the  latter  perhaps  in  large  quantities.  Haemoptysis  is  rare, 
but  does  occur  in  exceptional  cases.  Children  accustomed  to  a  sufficiency 
of  good  food  seldom  have  much  appetite,  and  often  show  a  complete  dis- 
gust for  food.  In  hospital  patients,  however,  the  appetite  may  remain 
keen  ;  and  a  child  with  cavities  in  his  lungs  and  a  high  temperature  may 
be  seen  to  enjoy  his  meals  almost  as  if  he  were  well.  The  digestion  is 
usually  impaired,  and,  probably  from  the  quantity  of  acrid  mucus  which  is 
swalloVed,  vomiting  is  not  uncommon.  Diarrhoea,  too,  is  a  familiar  symp- 
tom. In  cases  where  the  appetite  is  preserved  nutrition  may  seem  for  a 
time  to  go  on  fairly  well  in  spite  of  the  pyrexia.  Hospital  patients  often 
gain  weight  after  admission,  although  the  evening  temperature  may  stand 
every  night  at  102°  or  103°. 

The  physical  signs  in  the  stage  of  softening  consist  of  an  increase  in 
the  dulness,  for  the  irritation  set  up  by  the  changes  occurring  at  the  diseased 
spot  induces  an  extension  of  the  catarrhal  process  ;  and  an  alteration  in 
the  quality  of  the  breathing,  which  becomes  blowing  or  even  cavernous. 
It  is  accompanied  by  a  moist  crackling'  rhonchus  which,  as  a  cavity  fornis, 
becomes  very  metallic  and  ringing.  At  this  time  the  apex  of  the  opposite 
lung  should  always  be  carefully  examined.  In  many  cases  slight  loss  of  re- 
sonance with  high-pitched  or  faintly  bronchial  breathing  wiU  be  found  at 
the  supra-spinous  fossa,  and  a  click  or  dry  crackle  can  be  heard  at  the  end 
of  inspiration.  It  is  at  this  period  of  the  illness  that  diarrhoea  is  especially 
frequent ;  and  if  caseation  and  softening  occur  in  the  solitary  follicles  of 
the  intestine  and  the  glands  of  Peyer's  patches,  the  stools  may  soon  begin 
to  present  the  characters  peculiar  to  ulceration  of  the  mucous  membrane 
(see  page  662).  If  this  complication  occur,  the  child  wastes  rapidly  and  be- 
comes haggard  and  hoUow-eyed.  He  sweats  profusely  at  night ;  is  rest- 
less ;  refuses  food  ;  and  quickly  dies  with  all  the  symptoms  of  prostration. 
The  temperature  in  these  cases  seldom  reaches  a  high  elevation.  It  is 
usually  between  101°  and  102°  in  the  evening. 

Children  who  are  the  subjects  of  a  chi'onic  caseous  consolidation  of  the 
lung  often  suffer  from  attacks  of  secondary  catarrhal  pneumonia.  In  these 
attacks  the  boundaries  of  the  original  mischief  are  not  always  extended. 
It  is  common  to  find  the  chief  force  of  the  complication  expended  upon  a 
different  part  of  the  lung.  Thus,  a  child  with  signs  of  consolidation  at  the 
apex  of  the  right  lung  is  attacked  with  catarrhal  pneumonia.  A  loud  crep- 
itating rhonchus  is  heard  all  over  both  sides  of  the  chest,  and  at  the  right 
posterior  base  there  is  some  dulness  with  tubular  breathing  and  a  metallic 
quality  of  the  rhonchus.  The  basic  dxalness  becomes  gradually  more  pro- 
nounced, and  at  this  spot  the  respiration  gets  to  be  cavernous  or  even  am- 
phoric, and  the  rhonchus  to  be  excessively  metalUc  and  ringing.  The  vocal 
resonance  is  bronchophonic.  The  temperatui-e  rises  to  103°  or  104°  in  the 
evening.  After  two  or  three  weeks  the  temperature  begins  to  fall  and  the 
dulness  to  diminish  ;  the  hard  metallic  rhonchus  becomes  looser  and  more 
bubbling  ;  the  cavernous  breathing  is  less  intense  at  the  base,  and  the  gur- 
gling is  less  large  and  metaUic.  The  child  begins  to  regain  flesh,  and  when 
lost  sight  of,  although  looking  plump  and  well,  has  still  the  old  mischief  at 
the  apex,  and  the  signs  of  consolidation  with  cavernous  breathing  still  per- 
sist at  the  base  of  the  lung.  In  such  a  case,  which  is  no  imaginary  one,  the 
child  recovers  from  his  intercurrent  attack  with  two  consolidations  instead 
of  one.  The  catarrhal  pneumonia  has  given  rise  to  a  cheesy  deposit  at  the 
base  of  the  lung  and  dilatation  of  the  bronchi.  This,  of  com-se,  if  the 
patient  be  placed  under  favoiu'able  conditions,  may  possibly  be  recovered 
from  ;  but  the  probable  consequence  of  such  a  condition,  if  time  be  allowed 


CHKONIC  TUBEECULAE  PHTHISIS — SYMPTOMS.  511 

for  the  change,  is  the  development  of  a  fibroid  overgrowth  at  the  spot  and 
permanent  bronchiectasis. 

An  attack  of  broncho -pneumonia  is  often  a  cause  of  death,  or  the  patient 
dies  worn  out  with  fever,  diarrhoea,  cough,  and  want  of  sleep.  In  not  a 
few  cases  a  secondary  tuberculosis  supervenes,  or  the  case  may  be  comj^li- 
cated  by  a  more  chronic  and  less  general  formation  of  miliary  tubercle 
confined  to  the  lungs.  These  are  called  cases  of  tuherculo-pneumonic 
phthisis. 

CHRONIC  TUBERCULAR  PHTHISIS. 

In  this  form  of  the  disease  the  iUness  begins  in  a  very  gradual  manner, 
and  the  special  symptoms  arising  from  the  lungs  are  preceded  by  others 
showing  the  existence  of  general  disorder  of  health.  The  child  is  noticed 
to  be  languid  and  listless.  He  looks  pallid  ;  has  little  appetite  ;  complains 
of  pains  in  his  legs,  and  is  disinclined  for  his  usual  games.  He  is  often 
found  to  flush  at  night  and  his  hands  are  noticed  to  be  hot.  After  these 
symptoms  have  continued  for  several  weeks  the  patient  begins  to  have  a 
slight  cough.  This  at  first  is  merely  a  short  occasional  hack  which  excites 
little  attention  ;  but  after  a  time  it  becomes  more  frequent  and  annoying. 
The  course  of  the  illness  in  this  variety  is  less  ii-regular  than  in  that  previ- 
ously described ;  but  still  the  downward  progress  is  more  rapid  at  some 
times  than  at  others.  The  temperature,  although  it  undergoes  consider- 
able variations,  rarely  stands  at  a  normal  level  in  the  evening  ;  but  unless 
the  disease  be  complicated  with  catarrhal  pneumonia  the  pyrexia  is  not 
high  and  seldom  reaches  102°.  Wasting  is  usually  persistent ;  but  if  the 
patient  has  been  exposed  to  privation,  the  comforts  of  a  hospital  may  in- 
duce a  temporary  improvement  in  nutrition,  although  the  pyrexia  con- 
tinues and  the  other  symptoms  remain  unaltered.  Cough  for  a  long 
time  may  be  a  very  insignificant  symptom  and,  even  with  signs  of  extensive 
disease  of  the  lungs,  may  be  almost  absent.  The  breathing  is  often  rapid, 
rising  to  thirty  or  forty  in  the  minute.  Increased  hurry  of  breathing, 
according  to  Niemeyer,  may  be  one  of  the  earHest  local  symptoms,  occur- 
ring before  any  physical  signs  of  the  disease  can  be  discovered  in  the 
chest.  The  digestive  organs  are  weak  and  irritable.  Vomiting  is  common 
and  is  often  excited  by  cough.  Purging  is  also  a  frequent  symptom.  In 
many  cases  examination  of  the  belly  discovers  fatty  enlargement  of  the 
liver,  and  oedema  is  often  noticed  in  the  limbs.  Death  may  occur  from 
general  weakness,  from  catarrhal  pneumonia,  or  from  the  extension  of  the 
tubercular  formation  to  other  parts. 

The  physical  signs  of  tubercular  phthisis  appear  late,  and  at  first  are 
curiously  insignificant  when  compared  with  the  severity  of  the  general 
symptoms.  We  find  a  child  pale  and  thin,  with  a  depressed,  saddened  look. 
The  borders  of  his  mouth  have  a  faint  blue  tint ;  he  pants  after  exertion, 
and  coughs  occasionally  a  short  hard  hack.  We  are  told  that  he  has  been 
failing  for  several  months  ;  that  he  eats  scarcely  anything  ;  has  lost  all  his 
spirits,  and  gets  flushed  and  feverish  at  night.  On  examination  of  his 
chest  we  discover  merely  some  slight  want  of  resonance  at  the  apices  of 
the  lungs  with  weak,  harsh  breathing.  A  faint  dry  crackle  of  rhonchus  is 
caught  at  the  end  of  inspiration,  and  is  brought  out  more  clearly  by  a 
cough.  The  chest  is  elongated,  with  a  narrow  antero-posterior  diameter, 
but  the  lungs,  although  naturally  small,  appear  healthy  except  for  the 
signs  which  have  been  mentioned. 

As  the  disease  progresses  the  physical  phenomena  become  more  pro- 


512  DISEASE  IN   CHILDEEJSr. 

nounced.  They  are  always  discoverable  at  botli  apices,  although  more 
marked  on  one  side  than  on  the  other.  Usually  the  area  of  dulness  is  in- 
creased by  a  pneumonic  process  set  up  in  the  lung  ;  and  marked  dulness 
with  blowing  breathing  and  the  ordinary  signs  of  consolidation  are  dis- 
covered. The  disease  then  after  a  time  presents  much  the  same  characters 
to  physical  examination  as  those  referred  to  in  describing  the  catarrhal 
variety  of  phthisis.  In  exceptional  cases  disorganisation  goes  on  without 
the  aid  of  a  pneumonic  process.  We  then  find  the  feeble  breath-sound  to 
become  gradually  blowing,  and  eventually  cavernous  sounds  are  discovered 
at  the  apex. 

Tubercular  and  tuberculo-pneumonic  forms  of  phthisis  are  often  met 
with  in  scrofulous  children  who  suffer  from  long-standing  disease  of  the 
joints.  In  such  cases  the  articular  affection  has  probably  been  the  original 
cause  of  the  pulmonary  mischief  ;  and  by  the  continual  irritation  to  which 
it  gives  rise  may  influence  the  condition  of  the  patient  very  unfavourably. 
In  these  cases  it  is  often  advisable  to  remove  the  diseased  joint,  even  al- 
though the  amount  of  disease  in  the  lung  is  too  extensive  to  allow  of  last- 
ing improvement.  Life  may  be  considerably  prolonged  and  the  comfort 
of  the  patient  greatly  promoted  by  this  step. 

A  little  gii'l,  aged  eight  years,  was  a  patient  in  the  East  London  Chil- 
dren's Hospital  under  the  care  of  my  colleague,  Mr.  E.  W.  Parker.  The 
girl's  father  had  died  of  consumption,  and  she  herself  had  been  suffering 
from  strumous  disease  of  the  right  astragalus  for  six  months.  The  child 
was  much  emaciated  and  very  anaemic  and  feeble.  Her  skin  was  harsh  and 
dry,  her  eyelids  were  swollen  ;  and  the  cervical  and  inguinal  glands  of 
"  each  side  could  be  felt  to  be  enlarged.  The  finger  ends  were  somewhat 
thickened.  There  was  no  albumen  in  the  urine.  The  temperature  was 
tisually  normal  in  the  morning,  but  would  rise  towards  night  to  between 
101°  and  103°.  At  Mr,  Parker's  request  I  examined  the  child's  chest,  and 
found  the  signs  of  a  cavity  at  the  upper  part  of  the  right  lung,  with  evi- 
dence of  considerable  consolidation  over  the  lower  lobes.  The  left  lung 
was  also  diseased,  although  to  a  less  extent.  A  moist  crackHng  rhonchus 
was  heard  over  both  sides  of  the  chest.  Although  this  child  was  evidently 
suffering  from  tuberculo-pneumonic  phthisis,  and  the  pulmonary  mischief 
was  very  extensive,  the  system  was  obviously  so  greatly  distressed  by  the 
irritation  and  pain  of  the  diseased  ankle,  that  Mr.  Parker  decided  upon 
amputating  the  foot.  After  the  operation  the  temperature,  which  on  the 
previous  evening  had  been  101.6°,  fell  to  98°  at  6.30  p.  m.,  and  remained 
for  the  most  part  at  a  normal  level  while  the  child  remained  in  the  hospi- 
tal. The  clicking  rhonchus  also  ceased  to  be  heard  in  the  chest ;  the  face 
lost  its  distressed  look  ;  and  nutrition  improved  in  a  surprising  manner, 
the  patient  gaining  between  six  and  seven  pounds  in  three  weeks.  Unfor- 
tunately, after  the  child  left  the  hospital  and  returned  to  her  own  poor 
home,  the  improvement  was  not  maintained,  and  in  a  few  months  we  heard 
that  she  was  dead.  Still  the  remarkably  good  results  which  followed  the 
removal  of  the  diseased  joint  are  very  instructive,  and  fully  justified  the 
operation. 

The  majority  of  cases  of  pulmonary  phthisis  are  seen  in  children  of  six 
or  seven  years  and  upwards  ;  but  younger  children  and  even  infants  are 
subject  to  the  disease.  In  very  young  patients  ulceration  of  the  lung  is 
not  always  easy  to  recognise.  Serious  disease  may  be  present  without  giv- 
ing rise  to  any  very  characteristic  symptoms.  The  child  is  no  doubt  feeble 
and  wasted,  but  loss  of  flesh  and  strength  are  common  in  very  young  chil- 
dren with  almost  any  form  of  illness.    Cough  may  be  trifling  and  the  breath- 


CHRONIC   PULMONARY    PHTHISIS — DIAGNOSIS.  513 

ing  not  obviously  interfered  with.  Even  a  physical  examination  of  the 
chest  may  yield  us  little  information,  for  over  the  site  of  a  cavity  the  per- 
cussion note  may  be  merely  tubular  (tympanitic)  and  the  breathing  bron- 
chial with  moist  cUcking  sounds.  Moreover,  the  occurrence  of  softening 
in  a  cheesy  pulmonary  deposit  is  usually  a  signal  for  the  occurrence  of 
secondary  deposits  elsewhere ;  and  cheesy  and  ulcerating  intestinal  glands 
with  the  consequent  diarrhoea  may  completely  draw  away  the  attention  from 
the  lungs.  When  pulmonary  phthisis  occurs  in  the  young  child,  it  runs  a 
comparatively  rapid  course.  It  is  in  the  large  majority  of  cases  primarily 
of  the  catarrhal  form,  and  is  most  commonly  the  consequence  of  an  attack 
of  sub-acute  broncho-pneumonia  succeeding  to  measles  or  whooping-cough. 

Diagnosis. — In  the  diagnosis  of  pulmonary  phthisis  in  the  child  an  accu- 
rate account  of  the  beginning  and  course  of  the  illness  is  very  important. 
At  the  same  time  it  is  necessaiy  to  remember  that  a  history  of  cough  with 
persistent  loss  of  flesh  is  no  sufficient  proof  that  the  child  is  suffering  from 
pulmonary  consumption.  Scrofulous  children  and  others  with  a  like  sus- 
ceptibility to  chills,  are  very  subject  to  attacks  of  pulmonary  and  intestinal 
catarrh.  Such  patients  may  be  troubled  with  continual  cough,  and  lose 
flesh  steadily  without  any  organic  mischief  being  set  up  in  the  lung.  They 
may  even  be  feverish  at  the  onset  of  every  new  chill  without  this  additional 
symptom  being  evidence  of  phthisis.  No  doubt  the  condition  of  such  chil- 
dren is  one  of  danger,  for  they  often  eventually  develop  pulmonary  dis- 
ease ;  but  until  this  has  actually  taken  place,  ordinary  precautions  for  the 
avoidance  of  chills  will  quickly  cause  the  symptoms  to  disappear. 

Even  if  examination  of  the  chest  discovers  shght  dulness  at  the  supra- 
spinous fossa  of  one  side  with  a  high-pitched  or  faintly  bronchial  quality 
of  breathing,  these  signs  are  not  necessarily  due  to  phthisical  consolida- 
tion. AVeakly  children  are  very  liable  to  temporary  collapse  at  the  apices 
of  the  lungs  from  insufficient  expansion.  In  such  cases  the  morbid  signs 
are  limited  strictly  to  one  aspect  of  the  chest — the  back  or  the  front — and 
can  often  be  made  to  disappear  if  the  child  is  instructed  to  take  two  or 
three  full  inspirations  in  rapid  succession. 

In  young  subjects  consolidation,  as  a  result  of  catarrhal  pneumonia,  may 
be  met  with  at  all  parts  of  the  lung.  It  is  seen  as  often  at  the  base  as  at 
the  apex,  both  in  front  and  behind.  In  aU  cases,  therefore,  it  should  be 
made  a  rule  to  search  the  chest  completely  before  we  allow  ourselves  to 
exclude  the  existence  of  a  cheesy  deposit.  If  this  be  done  quietly  and 
gently,  as  directed  elsewhere  (see  page  13),  the  examination  can  usually 
be  carried  to  a  successful  issue.  In  infants,  as  has  been  abead}^  remarked,, 
phthisis  may  be  present  although  but  few  symptoms  of  the  disease  have 
been  noticed.  The  cough  may  be  insignificant,  the  breathing  quiet,  and 
a  looseness  of  the  bowels  of  some  standing  may  seem  to  explain  sufficiently 
the  pallor  and  wasting  of  the  body  and  the  distressed  expression  of  the 
child's  face.  If,  however,  at  the  same  time  the  evening  temperature  is 
higher  than  natural,  the  symptom  is  a  suspicious  one ;  and  if  the  state  of 
the  stools  indicates  the  existence  of  ulceration  of  mucous  membrane  (see 
page  662),  we  must  remember  that  this  condition  is  often  dependent  upon 
chronic  pulmonary  mischief.  In  every  case  the  physician,  if  he  do  his 
duty,  will  take  nothing  for  granted,  but  will  make  systematic  examination 
of  all  the  organs  of  the  body. 

A  distinction  between  the  catarrhal  and  tubercular  forms  of  phthisis  is 

readily  made  by  comparing  in  each  case  the  local  signs  with  the  general 

symptoms  of  the  disease.     Catarrhal  phthisis,  even  when  it  begins  at  the 

apex  by  slow  extension  of  the  catarrhal  process  to  the  pulmonary  alveoli, 

33 


514  DISEASE  IN   CHILDEEIS". 

produces  comparatively  little  impairment  of  the  general  nutrition  of  tlie 
body.  The  patient  coughs  and  is  a  little  feverish  at  night ;  but  his  appe- 
tite is  usually  good  ;  his  strength  is  httle  impaii'ed  ;  and  he  retains  a  fair 
amount  of  flesh.  E^^en  when  the  progress  of  the  disease  has  led  to  exten- 
sive consolidation  of  the  lung,  the  marked  contrast  between  the  mildness 
of  the  general  symptoms  and  the  severity  of  the  local  signs  discovered  by 
physical  examination,  is  sufiicient  to  reveal  the  nature  of  the  pulmonary 
mischief.  In  chronic  tubercular  phthisis  the  general  symptoms  are  severe 
from  the  first.  The  child  is  pale  and  thin,  feverish  and  languid,  for  some 
time  before  he  is  noticed  to  cough ;  and  it  is  still  some  time  longer  before 
examination  of  the  chest  discovers  any  positive  indication  that  the  lungs 
are  the  seat  of  pathological  change.  Moreover  in  catarrhal  phthisis,  ujitil 
softening  begins  in  the  deposit,  the  disease  is  confined  to  one  lung.  In 
tubercular  phthisis  the  physical  sig*ns,  when  they  do  present  themselves, 
are  discovered  at  both  apices. 

On  account  of  the  frequency  with  which  secondaiy  attacks  of  sub-acute 
catarrhal  pneumonia  compUcate  cases  of  old  consohdation,  dilated  bronchi 
are  often  present.  These  give  rise  to  all  the  signs  characteristic  of  excava- 
tion ;  and  it  is  very  important  to  satisfy  ourselves  as  to  the  nature  of  the 
pathological  condition.  Dilated  bronchi  are  most  common  in  the  child  at 
the  base  of  the  lung,  while  cavities  are  more  frequently  seated  nearer  to 
the  apex.  Therefore  the  situation  of  the  signs  at  the  base,  although  by  no 
means  conclusive  evidence,  points  rather  to  bronchiectasis  than  to  a  vomica. 
Again,  the  general  symptoms  are  of  great  importance.  Dilated  bronchi, 
xmless  occurring  as  a  chronic  condition  in  a  case  of  fibroid  induration  of 
the  lung,  are  met  with  towards  the  end  of  an  attack  of  broncho-pneumonia. 
If  then  we  find  that,  with  the  physical  signs  of  a  j)ulmonary  cavity,  the 
general  condition  of  the  child  is  improving  ;  that  the  temperatui-e  shows 
signs  of  falling  ;  the  appetite  improves,  and  the  flesh  and  strength  begin 
to  return,  the  evidence  is  strong  that  the  signs  are  not  the  consequence  of 
xdcerative  destruction  of  lung.  Moreover,  much  assistance  is  to  be  de- 
rived from  a  microscojDical  examination  of  the  sj^utum,  where  this  can  be 
obtained.  In  pulmonary  ulceration  areolar  fibres  of  yeUow  elastic  tissue 
vdll  be  seen  in  the  muco-pus  vomited  or  expectorated  ;  in  cases  of  bron- 
chiectasis these  will  be  absent.  Lastly  the  progress  of  the  signs  will  furnish 
corroborative  evidence.  Cavities  tend  to  grow  larger,  dilated  bronchi  to 
contract.  If,  therefore,  while  the  general  symptoms  remain  stationary,  the 
area  over  which  the  cavernous  signs  are  heard  is  found  to  extend  itself,  we 
cannot  but  conclude  that  disorganisation  of  lung  is  advancing  ;  while  if, 
with  general  improvement,  the  local  signs  diminish  in  intensity,  our  oj^inion 
that  these  are  due  to  dilatation  of  bronchi  receives  additional  confirmation. 

The  distinction  between  pulmonary  phthisis  and  fibroid  induration  of 
the  lung  is  considered  elsewhere  (see  jDage  478). 

Empyema  is  often  confounded  with  phthisis  ;  and  there  is  no  doubt 
that  the  general  ap^^earance  of  a  child  the  subject  of  old-standing  purulent 
effusion  is  very  like  that  of  a  consumptive  patient.  There  may  be  the 
same  hectic,  the  same  emaciation,  and  the  same  weakness.  In  each  case 
the  child  is  irritable  and  restless  with  a  hacking  cough,  some  shortness  of 
breath,  a  poor  appetite,  and  a  feeble  digestion.  On  examination  of  the 
chest  in  each  case  we  find  dulness,  often  extensive,  with  perhaps  loud 
cavernous  breathing.  But  the  history  of  the  illness  is  very  different  in  the 
two  diseases.  In  pleurisy  it  begins  with  pain  in  the  side  followed  after 
an  interval  hj  cough  ;  the  dulness  is  complete  with  extreme  sense  of  re- 
sistance ;  it  occupies  both  the  front  and  back  of  the  chest,  unless  the 


CUKOXIC    PULMOIS^AriY    PHTHISIS — PROGNOSIS.  515 

empyema  be  loculated  ;  and  reaches  clown  to  the  extreme  base.  Moreover, 
the  disease  is  strictly  limited  to  one  lung,  the  other  being  healthy  ;  and 
sighs  of  jDressure  are  noticed  ;  the  affected  side  is  expanded  ;  the  inter- 
costal spaces  are  less  hollowed  ;  and  the  heart's  apex  is  displaced.  On 
the  other  hand,  in  a  case  of  pulmonary  phthisis  sufficiently  extensive  to 
simulate  a  pleuritic  effusion,  the  opposite  lung  will  certainly  show  signs  of 
disease.  There  will  be  no  displacement  of  the  heart  or  bulging  of  the 
side  ;  the  dulness  will  not  be  complete  ;  the  resistance  to  percussion  will 
not  be  greatly  exaggerated,  if  no  gTeat  excess  of  fibroid  tissue  is  present ; 
and  the  breath-sounds  will  be  accompanied  by  a  large-sized  metallic 
gurgling  rhonchus.  In  either  case  the  vocal  resonance  will  i^robably  be 
bronchophonic  ;  but  in  emjDyema  it  often  has  an  segophonic  ciuality. 

Catarrhal  phthisis  in  the  young  subject  is  very  liable  to  be  complicated 
by  tuberculosis  as  a  result  of  infection  of  the  system  by  softeniug  cheesy 
matter.  The  occurrence  of  tuberculosis  is  sometimes  indicated  by  a  rise 
of  temperature  and  an  increase  in  the  rapidity  of  the  breathing  without 
any  extension  of  the  physical  signs.  Great  irritabihty  of  the  stomach  and 
bowels  is  often  induced  ;  the  child  vomits  repeatedly,  and  the  bowels  are 
relaxed.  Usually  in  these  cases  signs  of  intracranial  irritation  become 
quicldy  manifested  ;  and  convulsions  occur  followed  by  squinting,  ptosis, 
rigidity  of  joints,  and  other  well-known  signs  of  tubercular  meningitis. 

Prognosis. — The  gravity  of  the  case  in  the  two  forms  of  pulmonary 
phthisis  is  very  different.  In  an  early  stage  of  catarrhal  j^hthisis  we  may 
reasonably  hope,  by  putting  the  patient  into  the  best  sanitary  conditions, 
to  effect  removal  of  the  caseous  consolidation.  Absorption  of  a  chronic 
solidification  left  after  an  attack  of  catarrhal  pneumonia  may  be  effected 
in  the  young  subject  after  the  lapse  of  many  months  ;  and  I  have  often 
seen  cases  in  which  signs  of  pneumonic  phthisis  occuniug  at  the  apex, 
from  slow  extension  of  a  catarrh  to  the  alveoh,  have  disappeared  when  the 
child  has  been  sent  to  winter  in  a  suitable  climate.  Indeed,  if  we  can 
protect  the  patient  from  fresh  chills,  and  secure  for  him  an  adequate 
supply  of  perfectly  pure  air — such  conditions  with  good  and  sufficient 
food  will  do  much  to  help  him  on  his  way  to  recovery.  It  is  difficult  to 
say  at  what  peiiod  of  time  it  becomes  hopeless  to  expect  absorption  of  a 
cheesy  deposit.  I  beHeve  that  so  long  as  no  active  change  has  taken  place 
at  the  affected  spot  this  fortunate  tei-mination  to  the  case  is  stiU  possible 
if  the  patient  be  a  child. 

When  a  secondary  catarrhal  pneumonia  occurs  in  a  case  of  pneumonic 
phthisis  the  child  will  not  necessarily  die  ;  indeed,  the  acute  attack  usually 
runs  a  sub-acute  com-se  and  is  eventually  recovered  from.  Still,  the  future 
prospects  of  the  child  are  sensibly  darkened  by  the  addition  usuaUy  made 
to  the  amount  of  previously  existing  disease  by  the  passage  of  the  com- 
plication. 

Cases  of  chronic  tubercular  phthisis  always  go  on  from  bad  to  worse  ; 
for  although  by  a  suitable  chmate  and  the  careful  avoidance  of  chills,  at- 
tacks of  catarrhal  jDneumonia  may  be  prevented,  the  normal  course  of  the 
tubercular  disease  is  httle  affected  by  the  treatment. 

In  all  cases,  signs  of  very  unfavourable  import  are : — Great  rapidity  of 
breathing,  and  signs  of  hvidity  ;  a  high  evening  temperatui-e  ;  a  red  glazed 
tongue,  with  or  without  great  disturbance  of  the  stomach  ;  diarrhoea.  The 
scrofulous  constitution  or  a  strong  hei'editary  jDredisposition  to  phthisis  is 
an  element  in  the  case  of  the  utmost  gravity.  As  far  as  is  at  present  known, 
the  quantity  of  the  bacilh  discovered  in  the  sputa  furnishes  little  informa- 
tion of  importance  in  prognosis  ;  for  these  organisms  are  not  foxmd  to  be 


516  DISEASE   I]Sr   CHILDEE]Sr. 

necessarily  most  numerous  in  cases  where  the  diseased  processes  are  most 
active. 

Treatment. — Children  born  into  families  in  which  there  is  a  consump- 
tive tendency  require  special  care  in  theii*  bringing  up  ;  and  every  avail- 
able means  should  be  adopted  to  counteract  their  unfortunate  predisposi- 
tion. Infants  should,  if  possible,  be  suckled  by  a  healthy  wet-nurse,  and 
every  precaution  should  be  taken  to  ensure  the  purity  of  the  air  they 
breathe.  As  they  grow,  they  should  be  accustomed  to  warm  clothing, 
perfect  cleanliness,  and  regularity  of  meals.  Their  food  should  be  plain 
and  well  selected,  avoiding  excess  of  sweets  and  farinaceous  matters,  which 
are  so  apt  to  excite  and  maintain  an  acid  condition  of  the  alimentary  canal. 
Their  residence  should  be,  if  possible,  on  a  dry  soil  and  in  a  bracing  air. 
If  this  be  not  practicable,  they  should  at  any  rate  be  sent  away  to  a  more 
suitable  habitation  during  the  spring  and  fall  of  the  year — times  when 
the  changeable  season  is  so  prejudicial  to  delicate  children.  They  should 
be  trained  regularly  to  strengthen  their  muscles  by  out-door  games  ;  and 
if  the  lungs  are  small,  and  the  chest  consequently  narrow,  every  means 
should  be  resorted  to  to  invigorate  the  pectoral  muscles  and  expand  the 
carity  of  the  chest.  All  forms  of  catarrh  should  be  attended  to  with 
peculiar  care,  and  the  parents  shorfld  be  warned  that  neglect  of  such  de- 
rangements may  entail  the  most  serious  consequences.  By  such  means  a 
child  naturaUy  delicate  may,  as  he  grows  up,  appear  to  cast  off  many  of 
the  external  signs  of  his  constitutional  tendency'  ;  and  although,  no  doubt, 
still  exceptionall}^  sensitive  to  unhealthy  influences,  may  preserve  his  vigour 
under  conditions  which  would  quickly  prove  injurious  to  another  less  care- 
fully nui'tured.  A  cold  douche  in  the  morning  on  rising  from  bed  is  of 
great  service  in  these  cases  ;  and  if  the  shock  is  too  great  under  ordinary 
conditions,  the  bath  will  be  readily  borne  w^hen  given  with  the  precautions 
recommended  in  a  previous  chapter  (see  page  17). 

If  a  child  with  such  a  tendency  be  attacked  by  measles  or  whooping- 
cough,  the  parents  should  be  warned,  as  the  disease  subsides,  of  the  dan- 
ger of  neglecting  the  catarrhal  complications  which  are  so  hable  to  occur 
in  the  later  stages  of  these  siDecific  maladies.  In  every  case  where  it  is 
possible  the  patient  should  be  sent  for  his  convalescence  to  a  good  sea-side 
air.  If  catarrhal  pneumonia  have  occurred,  the  clearing  up  of  the  consoh- 
dation  must  be  carefully  watched.  Good  ventilation  and  careful  dieting 
are  more  than  ever  necessary  ;  and  if  absorption  apjDcar  to  flag,  measures 
should  be  taken  at  once  to  alter  the  conditions  under  which  the  j^atient  is 
living,  and  a  change  of  air  should  be  insisted  upon.  Alkalies  and  alkahne 
sprays  are  very  useful  in  these  cases,  and  the  citrate  of  iron  and  quinine 
may  be  given  with  the  citrate  of  jDotash  with  gi'eat  advantage. 

In  cases  of  acute  phthisis  energetic  measui'es  must  be  adopted.  We 
should  at  once  take  steps  to  reduce  the  pjorexia,  which  is  considerable,  and 
to  maintain  the  strength  of  the  patient.  Dr.  McCall  Anderson  recommends 
the  apj)lication  of  cold,  either  by  iced  cloths,  Leiter's  temperatin-e  regula- 
tors, or,  if  these  means  fail,  by  cold  baths.  He  has  found  the  application 
to  the  abdomen  of  cloths  wrung  out  of  ice-cold  water  and  frequently  re- 
newed, very  useful  in  lowering  the  temperature,  and  speaks  highly  of  Nie- 
meyer's  combination  of  digitalis,  quinine,  and  ojDium.  I  cannot  myself  say 
that  I  have  seen  much  benefit  result  from  this  form  of  medication,  but  if 
thought  desirable,  half  a  grain  each  of  the  two  former  drugs  may  be  given 
with  an  eighth  or  tenth  of  a  grain  of  ojDium  every  four  hours  to  a  child  of 
ten  years  old.  Of  other  drugs,  large  doses  of  quinine  seem  to  have  only 
a  temporary  effect,  and  the  salicylates  in  my  hands  have  proved  worse  than 


CHEONIC    PUL]\rON"ART  PHTHISIS — TREATMEISTT.  517 

useless  as  anti-pyretics.  They  seem  to  exert  little  influence  upon  the  tem- 
peratui'e,  while  they  irritate  the  stomach  and  cause  nausea.  Our  chief  re- 
source for  reducing  the  temperature  in  this  as  in  other  forms  of  febrile 
disease,  consists  in  the  apphcation  of  cold. 

In  order  to  maintain  the  strength  Dr.  Anderson  recommends  hourly 
feeding,  both  day  and  night,  with  simple  food,  such  as  milk,  broths,  etc., 
and  gives  brandy  or  other  stimulant  as  seems  to  be  required.  The  profuse 
sweats  must  be  controlled  by  the  subcutaneous  injection  of  atropine  (gr.  y^q-). 
According  to  this  author  the  most  striking  results  may  be  sometimes  ob- 
tained, and  a  complete  cure  occasionally  effected  by  the  above  means. 

In  the  chronic  forms  of  phthisis  it  is  also  of  the  utmost  importance  to 
improve  the  nutrition  of  the  body.  The  absorption  of  recent  deposits  and 
the  obsolescence  of  more  chronic  consolidations  are  best  promoted  by 
plenty  of  fresh  aii',  the  avoidance  of  chills,  and  a  liberal  supply  of  good 
food.  In  order,  however,  that  the  child  may  profit  by  an  abundant  dietary, 
it  is  essential  that  his  digestive  organs  should  be  maintained  in  a  high  state 
of  efficiency.  The  subjects  of  pulmonary  phthisis  resemble  in  one  respect 
hand-fed  infants.  Like  them  they  are  liable  to  repeated  attacks  of  gastro- 
intestinal catarrh,  which  gives  rise  to  indigestion  and  flatulence.  These 
attacks,  by  the  influence  they  exercise  upon  general  nutrition,  may  produce 
very  serious  consequences.  If  a  child  with  disordered  stomach  be  fed  con- 
tinually with  food  which  he  has  no  means  of  digesting,  not  only  is  the 
gastric  dei'angement  protracted,  but  his  system  is  kept  in  a  state  of  fever 
which  often  culminates  in  a  fresh  attack  of  pneumonia.  In  any  case,  such 
a  condition  of  the  body  is  not  calculated  to  encourage  the  healthy  removal 
of  morbid  products.  In  aU  these  attacks  the  diet  should  be  at  once  al- 
tered. The  child  should  take  for  food  little  but  milk  alkalinised  with  lime 
drops  and  diluted  with  barley  water,  weak  broth,  and  dry  toast.  For  medi- 
cine he  may  have  an  alkali  with  nux  vomica  to  act  as  an  antacid  and  stom- 
achic.    By  this  means  the  gastric  derangement  will  be  quickly  overcome. 

In  all  cases  where  the  parents  are  in  a  position  to  afford  the  expense,  a 
change  of  climate  is  of  great  service.  A  child  who  is  the  subject  of  an  un- 
absorbed  pneumonic  deposit,  whether  this  succeed  to  an  attack  of  broncho- 
pneumonia, or  have  occurred  more  slowly  from  neglected  catarrh,  should 
change  the. conditions  under  which  he  has  been  living.  If  he  reside  at  the 
sea-side,  he  should  be  sent  inland  ;  if  inland,  he  should  be  sent  to  the  sea- 
side. A  good  sea  voyage  often  brings  about  a  complete  cure  in  these  cases. 
The  body  should  be  warmly  clothed,  the  bed-room  should  be  large,  airy, 
and  well  ventilated,  and  the  child  should  pass  a  large  part  of  the  day  out 
of  doors  whenever  the  weather  permits.  Cod-liver  oil  is  useful  as  a  help 
to  the  treatment,  but  not  as  a  substitute  for  it ;  and  iron  and  quinine  with 
an  alkali  should  be  prescribed  as  already  recommended. 

When  softening  begins  at  the  seat  of  mischief  and  evident  constitutional 
symptoms  are  observed,  the  child  should  be  carefully  protected  from  chills, 
and  at  the  same  time  be  insured  a  plentiful  supply  of  fresh  air.  Mild 
counter-irritants  should  be  applied  to  the  chest  over  the  diseased  spot, 
such  as  painting  with  tincture  of  iodine  or  rubbing  in  a  weak  croton-oil  lin- 
iment. The  hypophosphite  of  lime  (gr.  iij.-v.)  is  of  sensible  value  in  these 
cases,  and  will  often,  when  debility  and  weariness  are  complained  of,  cause 
an  immediate  improvement  in  the  strength.  In  other  cases  arsenic  is  of 
great  service,  and  may  be  given  with  quinine  in  doses  of  three  to  five 
minims  of  the  arsenical  solution  three  times  a  day.  Lately  iodoform  has 
been  recommended  with  the  object  of  reducing  secretion,  moderating  fever 
and  cough,  and  arresting  the  progress  of  caseation.     I  have  seen  benefit 


518  DISEASE   IlSr   CHILDRElSr. 

result  from  half-grain  doses  of  the  remedy  given  three  times  a  day  with 
extract  of  gentian.  If  the  pyrexia  is  high,  it  may  be  reduced  by  sponging 
the  surface  -with  tepid  water ;  and  night-sweats  are  usually  readily  con- 
trolled by  one  or  two  drops  of  the  liq.  atropise  at  bedtime  given  in  a  tea- 
spoonful  of  water. 

Tor  some  years,  and  especially  since  the  discovery  by  Koch  of  the 
"tubercle  bacillus,"  antisejjtic  inhalations  have  come  greatly  into  favour. 
At  night  the  air  of  the  bed-room  may  be  impregnated  with  the  fumes  of 
tar  or  creasote  by  Dr.  J.  R  Lee's  "  steam-draught  inhaler  "  or  some  similar 
instrument.  In  the  day-time,  by  means  of  a  perforated  metal  respii-ator, 
such  as  that  devised  by  Dr.  Coghill,  of  Ventnor,  various  antiseptic  sub- 
stances may  be  inhaled  for  an  hour  at  a  time  more  or  less  frequently  dur- 
ing the  day.  At  the  Victoria  Park  Hospital  we  have  been  in  the  habit  of 
using  for  this  purpose  a  preparation  composed  of  two  drachms  each  of  the 
etherial  tincture  of  iodine  and  carbolic  acid,  one  drachm  of  creasote,  and 
one  ounce  of  i-ectified  spirit.  Of  this  ten  drops  are  poured  upon  a  piece 
of  cotton  wool  and  used  in  the  respirator  several  times  in  the  day.  In 
many  cases  it  is  well  to  use  the  antiseptic  frequently  ;  and  if  the  child  will 
submit  to  the  inconvenience  he  may  be  made  to  wear  the  respirator  all 
day  long.  In  such  a  case  the  antiseptic  drops  can  be  renewed  every  two 
or  three  hours.  Very  good  results  are  often  obtained  by  the  help  of  this 
method  of  medication.  The  violence  of  the  cough  is  often  diminished 
after  the  respirator  has  been  worn  for  a  short  time,  and  the  sputum  is 
more  readily  brought  away  from  the  lungs.  Expectorant  mixtures  will 
often  have  to  be  given  in  addition.  The  disadvantage  of  all  these  drugs, 
however,  is  their  unfortimate  tendency  to  cause  derangement  of  the 
stomach.  When  made  use  of  it  is  advisable,  if  possible,  to  combine  the 
expectorant  with  an  alkali  or  a  mineral  acid.  If  the  cough  is  hard  and  tight, 
a  few  drops  of  ipecacuanha  wine  should  be  given,  with  five  or  six  grains  of 
bi-carbonate  of  soda,  in  a  draught  sweetened  with  glycerine.  Afterwards, 
when  secretion  is  more  copious,  four  or  five  drops  of  sal  A^olatile  may  be 
combined  with  a  drop  or  two  of  liq.  morphia;,  or  five  to  fifteen  drops 
of  i^aregoric,  in  glycerine  and  water.  These  may  be  followed  by  an  alka- 
line and  iron  mixture,  or  a  draught  containing  pernitrate  of  iron  and  dilute 
nitric  acid.  Cod-liver  oil  should  always  be  given  if  it  can  be  borne.  When 
this  does  not  agree,  maltine  often  proves  a  good  substitute,  and  is  usually'' 
taken  readily  by  a  child. 

In  all  cases  the  state  of  the  digestive  organs  must  be  watched  with  the 
greatest  vigilance,  and  any  sign  of  acidity  or  flatulence  must  be  a  signal 
for  a  prompt  reconsideration  of  the  dietary.  Pepsin  is  often  useful  given 
with  dilute  hydrochloric  acid  and  strychnia,  as  recommended  elsewhere 
(see  page  641).  If  a  difficulty  is  foimd  in  digesting  starches,  the  liq. 
pejDticus  (Benger)  given  with  an  alkali  about  an  hour  after  meals  is  of 
service.  In  such  cases,  also,  the  measures  recommended  for  the  treat- 
ment of  chronic  diarrhoea  may  be  adopted  with  advantage  (see  page  640). 

If  the  cough  excite  vomiting,  this  symptom  can  be  generally  allayed  by 
the  administration  of  one  drop  of  Fowler's  solution  of  arsenic  before  a 
meal ;  or  half  a  drop  of  liq.  strychnise  often  has  an  equally  beneficial  action. 
If  haemoptysis  occur,  the  child  should  be  kept  perfectly  quiet  in  bed  ;  fluids 
should  be  given  to  him  in  small  quantities  at  a  time,  and  he  may  take  fif- 
teen to  twenty  drops  of  the  liquid  extract  of  ergot  with  mildly  aperient  doses 
of  Epsom  salts  three  times  a  day.  If,  however,  the  bowels  are  ulcerated, 
the  saline  laxative  must  be  omitted.  Dian*hoea  dependent  upon  this  in- 
testinal lesion  must  be  treated  as  recommended  elsewhere  (see  page  666). 


CHAPTEK  XIII. 

PAROXYSMAL  DYSPNOEA. 

DysPN(EA  is  a  symptom  frequently  met  with  in  early  life.  The  term  does 
not  denote  merely  increased  rapidity  of  breathing.  The  respiratory  move- 
ments may  be  hurried  without  the  patient's  being  sensible  of  any  unusual 
effort  in  the  act  of  breathing  or  of  suffering  from  imperfect  aeration  of  the 
blood.  To  constitute  dyspncea  there  must  be  perceptible  distress  ;  and  the 
term  may  be  defined  as  a  conscious  embarrassment  in  the  performance  of 
the  respiratory  function. 

Dyspnoea  is  by  no  means  confined  to  cases  of  pulmonary  mischief ;  in- 
deed, in  the  child,  extreme  difficulty  and  labour  of  breathing,  with  great 
lividity  of  face,  although  possibly  produced  by  disease  of  the  lung,  is  yet 
more  commonly  the  consequence  of  some  other  cause.  The  most  urgent 
and  alarming  form  of  dyspnoea  is  seen  in  cases  of  impediment  to  the  pas- 
sage of  air  through  the  glottis.  We  find  it  carried  to  its  highest  point  in 
stridulous  and  membranous  laryngitis,  in  obstruction  of  the  windpipe  by 
a  foreign  body,  in  extra  laryngeal  pressure  from  an  abscess  in  the  pharynx, 
and  in  pressure  upon  the  trachea  or  a  large  bronchus  by  a  mass  of  enlarged 
glands.  Again,  intense  dyspnoea  may  be  found  in  a  case  where  air  pene- 
trates freely  into  the  lungs.  If  the  circulation  through  the  pulmonary 
vessels  is  obstructed,  as  when  a  clot  is  slowly  forming  in  the  pulmonary 
artery,  the  suffering  from  deficient  aeration  of  blood  may  amount  to  an 
agony.  So,  also,  in  serious  disease  of  the  heart  dyspnoea  is  a  common 
symptom,  for  the  passage  of  blood  through  the  lungs  is  impeded  by  the 
valvular  lesion. 

Again,  external  pressure  upon  the  lung  will  excite  a  very  pronounced 
feehng  of  dyspnoea.  When  one  lung  is  entirely  compressed,  and  the  heart 
dislocated  by  a  copious  liquid  effusion  into  the  pleura,  dyspnoea  may  be 
urgent  and  threaten  actual  suffocation.  When  the  ribs  are  greatly  soft- 
ened, as  in  a  case  of  advanced  rickets,  the  pressure  of  the  atmosphere  upon, 
the  yielding  chest-walls  may  cause  such  impediment  to  the  expansion  of  the 
lungs  that  serious  dyspnoea  may  be  induced.  If  at  the  same  time  the  de- 
scent of  the  diaphragm  is  impeded  by  accumulation  of  flatus  in  the  belly, 
the  danger  is  really  imminent.  On  the  other  hand,  in  cases  of  actual  pul- 
monary mischief  dyspnoea  is  not  always  present.  We  find  it,  indeed,  in 
catarrhal  pneumonia  and  bronchitis,  especially  if  the  latter  disease  is  ac- 
companied by  any  occlusion  of  the  tubes  ;  but  in  other  cases  of  interfer- 
ence with  the  pulmonary  function  it  is  exceptional  to  see  signs  of  suffering 
from  conscious  want  of  air  cai'ried  to  an  extreme  degree.  Even  in  ad- 
vanced phthisis  distress  fi"om  this  cause  is  rarely  great  ;  and  in  croupous 
pneumonia  and  collapse  of  the  lung  the  respirations,  although  greatly 
quickened,  are  accompanied  hj  little  or  no  exaggeration  of  movement,  and 
dyspnoea  in  the  sense  of  an  active  feehng  of  oppression  of  the  chest  cannot 
be  said  to  exist. 


520  DISEASE   IN   CHILDEElSr. 

In  every  case  of  dyspnoea  we  have,  therefore,  to  examine  very  carefully 
in  order  to  discover  the  cause  to  which  the  impediment  to  respu-ation  may 
be  correctly  attributed.  As  a  rule,  perhaps,  dyspnoea  is  irregular  in  its 
severity.  It  is  subject  to  temporary  increase  and  diminution,  so  that  the 
patient  from  a  condition  of  great  distress  may  pass  into  a  state  of  com- 
parative ease.  The  term  "paroxysmal  dyspnoea  "  is,  however,  confined  to 
cases  where  the  difficulty  of  breathing  occurs  in  attacks  of  variable  sever- 
ity, which  last  a  longer  or  shorter  time  and  then  pass  completely  away. 

There  are  certain  rare  causes  of  remittent  dyspnoea  in  the  child  which 
may  be  mentioned.  These  are — paralysis  of  the  respiratory  muscles  and  of 
the  diaphragm,  such  as  may  occur  as  a  sequel  of  diphtheria  (see  page  100) ; 
interstitial  oedema  of  the  lung  from  acute  Bright's  disease  (see  page  39)  ; 
and  clotting  of  blood  in  the  pulmonary  artery  (see  page  98).  These  lesions 
are,  however,  exceptional,  and  the  dyspnoea  they  induce  is  not  paroxysmal 
in  the  correct  sense  of  the  word  ;  for  although  the  feeling  of  suffocation 
moderates,  it  does  not  entirely  subside. 

As  commonly  met  with  in  the  child,  paroxysmal  dyspnoea,  i.e.,  dyspnoea 
occurring  in  paroxysms  with  intervals  of  complete  intermission,  is  a  result 
of  the  following  causes  : 

Stridulous  laryngitis. 

Pressure  upon  the  trachea  or  a  large  bronchus  by  swollen  bronchial 
glands. 

Obstruction  of  a  bronchus  by  a  foreign  body. 

True  bronchial  asthma,  occurring  often  in  the  course  of  chronic  bron- 
chitis and  emphysema. 

Of  these  the  first-named  disease  is  fully  considered  elsewhere.  It  re- 
quires no  further  notice  in  this  place,  as  the  severity  of  the  laryngeal  symp- 
toms at  once  indicates  the  seat  of  the  impedient  to  respiration.  The  other 
forms  of  paroxysmal  dyspnoea  are  often  confounded  together  under  the 
common  name  of  "  asthmatic  attacks."  Dyspnoea  arising  from  the  press- 
ure of  enlarged  bronchial  glands  and  the  difficulty  of  breathing  induced 
by  the  presence  of  a  foreign  body  in  the  air-tubes  are  described  in  other 
parts  of  this  treatise.  They  wall,  however,  be  again  referred  to  in  discuss- 
ing the  diagnosis  of  asthma. 

Bronchial  asihvia  is  comparatively  seldom  met  with  in  the  child.  When 
it  occurs  at  this  period  of  life,  it  appears  to  be  almost  invariably  the  con- 
sequence of  whooping-cough  or  catarrhal  pneumonia.  The  seizures  always 
assume  the  "catarrhal  f orm  ;"  indeed,  the  subjects  of  the  disease  are 
usually  sufferers  from  emphysema  of  the  lungs,  and  the  attack  of  dysj)noea 
occurs  as  a  consequence  of  a  fresh  catarrh.  In  many  cases  the  child  comes 
of  a  gouty  family,  and  sometimes  the  pulmonary  disease  appears  to  be 
hereditary.  The  tendency  to  asthma  is  occasionally  associated  with  a  ten- 
dency to  general  eczematous  eruption  ;  and  Dr.  West  states  that  he  has 
never  known  eczema  to  be  very  extensive  and  very  long  continued  without 
a  marked  liability  to  asthma  being  associated  with  it.  The  two  affections 
may  alternate — the  one  subsiding  when  the  other  appears— as  in  the  case 
of  a  boy  of  six  years  old  referred  to  by  Caillaut ;  but  they  may  be  also  co- 
existent, and  the  cure  of  the  one  is  often  followed  by  the  disappearance 
of  the  other. 

The  exciting  causes  of  the  attack  appear  to  be  in  most  cases  the  inhala- 
tion of  some  irritating  matters,  either  in  fine  dust  or  vapour,  directly  into 
the  air-tubes.  A  paroxysm  sometimes  follows  an  indigestible  meal,  or  is 
induced  by  food  imperfectly  masticated  and  hurriedly  swallowed.  It  has 
been  consequently  suggested  that  irritation  of  the  gastric  filaments  of  the 


PAEOXYSMAL   DYSPNCEA — BEOWCHIAL   ASTH:MA.  621 

pneumogastric  may  be  reflected  to  tlie  pulmonaiy  branches  of  the  nerve, 
and  through  them  set  up  spasm  of  the  tubes.  But  the  theory  of  reflex 
action  is  surely  exposed  to  a  severe  strain  by  such  an  explanation. 

Without  expressing  any  opinion  upon  the  vexed  question  of  the  nature 
of  the  asthmatic  seizure — whether  it  be  a  pure  neurosis  (as  is  commonly 
held)  or  not — I  may  observe  that  it  is  at  least  curious  that  in  children, 
whose  tendency  to  nervous  spasm  of  every  kind  is  one  of  the  physiological 
peculiarities  of  early  life,  pure  asthma  shovdd  be  an  affection  so  rarely  met 
with  ;  that  while  general  convulsions  may  be  induced  by  peripheral  irrita- 
tion of  various  degrees  of  severity,  while  spasmodic  contraction  bf  the 
glottis  may  be  set  up  by  a  trifling  laryngeal  catarrh,  an  attack  of  paroxys- 
mal dyspnoea  from  spasmodic  occlusion  of  the  smaller  air-tubes  should  be 
a  phenomenon  of  such  infrequent  occiu'rence.  That  it  is  extremely  rare 
there  can  be  no  doubt.  Of  the  recorded  cases  of  asthma  in  young  children 
there  are  very  few  in  which  direct  pressure  upon  the  bifurcation  of  the 
trachea  or  a  main  bronchus  by  enlarged  bronchial  glands  can  be  excluded. 
I  have  seen  many  cases  of  so-called  asthma  in  the  child,  but  have  rarely 
failed  to  find  evidence  of  swelling— often  of  considerable  swelling — of  these 
glands. 

Symptoms. — Asthmatic  children,  as  has  been  said,  are  usually  the  sub- 
jects of  emphysema.  This  condition  often  gives  little  evidence  of  its  pres- 
ence until  the  lungs  are  attacked  by  a  fresh  cataiTh.  Tlie  breathing  then 
becomes  excessively  oppressed,  so  that  the  child  is  unable  to  lie  down  in 
his  bed.  The  face  is  pale,  with  a  dusky  tint  rou^nd  the  mouth  and  eyes ;  the 
eyes  are  staring  and  congested  ;  the  mouth  is  open  ;  the  lips  are  purple  ;  the 
nostrils  work  violently,  and  the  forehead  is  covered  with  beads  of  sweat. 
The  child  is  very  restless,  throwing  about  his  arms,  and  his  face  expresses 
great  suffering.  His  heart  acts  violently  and  ii-regularly,  but  the  pulse  is 
small  and  weak.  When  the  chest  is  uncovered,  all  the  respiratory  muscle?' 
are  seen  to  be  in  action,  but  the  chest  remains  fully  distended  and  move' 
but  shghtly  at  each  breath.  There  is  little  hurry  of  breathing  on  accoun  " 
of  the  increased  length  of  expiration,  and  the  temperature  is  not  elevated 
The  cough  is  usually  short  and  dry,  but  not  at  all  paroxysmal. 

On  examination  of  the  chest  during  an  attack  we  find  general  hyper- 
resonance  of  the  percussion  note  ;  the  vesicular  mui-mur  is  either  very  fee- 
ble or  completely  suppressed,  and  is  often  quite  covered  by  large  sonoro- 
sibilant  rhonchus.     At  the  base  copious  subcrepitant  rales  may  be  heard. 

The  attack  lasts  for  a  variable  time.  It  usually  continues  more  or  less 
severely  for  two  or  three  da3^s,  and  then  gradually  subsides.  As  a  rule,  the 
more  severe  the  dyspnoea,  the  shorter  its  duration  ;  but  for  days  or  even 
weeks  after  the  attack  is  over  the  child  may  wake  up  wheezing  in  the  morn- 
ing, and  his  breath  may  be  short  for  some  houi-s  after  rising  from  his 
bed. 

Sometimes  the  onset  of  the  attack  is  heralded  by  severe  coryza,  with  re- 
peated sneezing,  and  this  is  quickly  followed  by  distressing  dyspnoea.  The 
oppression  of  breathing  seems  sometimes  to  threaten  actual  suffocation  and 
in  aU  cases  the  severity  of  the  suffering  from  want  of  air  is  out  of  all  pro- 
portion to  the  insignificant  character  of  the  physical  signs.  The  seizui-e, 
however,  invariably  ends  in  recoveiy.  After  a  time  the  breathing  becomes 
easier,  and  eventually  all  distress  is  at  an  end  ;  but  before  the  termination 
of  the  attack  is  reached  there  may  be  many  alternations  in  the  intensity  of 
the  dyspnoea,  and  even  after  the  days  have  become  peaceful  the  nights 
may  still  be  disturbed  by  a  return  of  the  paroxysms. 

Diagnosis. — In  cases  of  paroxysmal  dyspnoea  it  is  important  with  regaxd 


522  DISEASE   IK   CHILDEEN". 

both  to  prognosis  and  treatment  to  ascertain  the  exact  cause  of  the  dis- 
tressing symptom. 

When  the  dyspnoea  is  due  to  occlusion  of  the  larynx  from  spasm,  from 
impaction  of  a  foreign  body,  or  from  the  pressure  of  a  retro-pharyngeal 
abscess,  the  difficulty  lies  chiefly  in  inspkation.  As  each  breath  is  drawn 
the  soft  parts  of  the  chest  sink  in  and  the  epigastrium  is  deeply  retracted. 
The  inspiration  is  excessively  long  and  laborious,  the  expiration  short  and 
comparatively  easy.  At  the  same  time  crowing  sounds  are  produced  in  the 
glottis  and  point  unmistakably  to  the  seat  of  the  impediment. 

In  cases  where  the  hindrance  to  respiration  is  seated  at  a  lower  level, 
as  when  a  main  bronchus  is  obstructed  by  a  foreign  body,  or  the  trachea 
at  its  bifurcation  is  compressed  by  a  mass  of  swollen  glands,  and  also  in 
cases  of  bronchial  asthma,  the  distress  is  chiefly  seen  in  expiration,  which 
is  prolonged,  laborious,  and  ineffectual.  Attacks  of  dyspnoea  from  these 
causes  require  to  be  very  carefully  discriminated,  as  they  are  all  commonly 
spoken  of  as  "  asthmatic  attacks."  The  most  frequent  of  these  in  children, 
beyond  all  comparison,  is  enlargement  of  the  bronchial  glands  ;  and  most 
cases  of  "  asthma  "  in  early  life  are  due  to  direct  pressure  by  swollen  glands 
upon  the  air-tubes.  Scrofulous  children  are  very  sensitive  to  chills  and 
readily  take  cold.  They  are  consequently  frequent  sufferers  from  pulmo- 
nary catarrh.  In  these  attacks  the  glands  undergo  a  rapid  temporary  in- 
crease in  size,  and  their  enlargement  may  set  up  serious  pressure  upon  the 
windpipe  at  its  bifurcation. 

Dyspnoea  from  this  cause  is  often  intense,  and  comes  on  in  violent  par- 
oxysms which  usually  occur  at  night.  The  character  of  these  seizures  has 
been  elsewhere  described  (see  page  182).  In  such  cases  there  is  not  al- 
ways dulness  at  the  upper  part  of  the  sternum,  or  between  the  scapulae ; 
for  alteration  of  the  percussion-note  can  only  be  noticed  in  cases  where  the 
swoUen  glands  are  in  contact  with  some  part  of  the  chest-wall.  The  chief 
collection  of  bronchial  glands  lies  in  the  bifurcation  of  the  trachea  ;  but 
others  are  distributed  along  the  course  of  the  bronchi  as  far  as  the  third  or 
fourth  subdivisions.  Enlarged  glands,  therefore,  may  be  found  after  death 
deep  in  the  substance  of  the  lung,  as  described  by  Cruveilhier.  The  effect 
of  enlargement  of  these  bodies  is  to  press  upon  and  flatten  the  aii--passages  ; 
and  if  the  calibre  of  the  tube  be  at  the  same  time  lessened  by  viscid  secre- 
tion, the  channel  for  the  time  may  be  completely  occluded.  By  such  means 
the  most  serious  dyspnoea  may  be  produced. 

A  little  girl,  between  three  and  four  years  old,  was  said,  to  be  subject  to 
feverish  attacks  which  lasted  from  a  few  days  to  a  week.  In  these  the  child 
first  showed  symptoms  of  catarrh  and  then  began  to  suffer  from  urgent 
dyspnoea.  In  the  last  of  these  attacks,  as  described  to  me,  the  breathless- 
ness  began  quite  suddenly  at  night  and  woke  the  child  up  from  her  sleep. 
She  was  said  to  have  started  up  gasping  in  the  utmost  distress,  and  her 
voice  was  hoarse.  After  about  an  hour  the  paroxysm  subsided  and  the 
child  had  a  violent  attack  of  spasmodic  cough,  retching  up  much  phlegm. 
The  seizures  were  repeated  for  six  nights  in  succession,  becoming,  how- 
ever, less  severe  towards  the  end  of  this  period.  In  the  daytime  the  pa- 
tient seemed  fairly  well,  although  towards  evening  her  breathing  would  be 
a  little  short.  Her  nose  also  bled  a  great  deal.  This  httle  girl  was  brought 
to  me  some  time  after  the  last  attack  had  subsided,  when  she  had  returned 
to  her  usaal  health.  The  jugular  veins  on  each  side  of  the  neck  were  then 
noticed  to  be  full,  and  the  venous  radicles  on  the  front  of  the  chest  to  be 
unnaturally  visible.  There  was  a  suspicion  of  duhaess  on  the  upper  bone 
of  the  sternum,  and  when  the  child  bent  her  head  backwards  a  venous  hum 


PAROXYSMAL  DYSPISTCEA — DIAGNOSIS.  623 

was  heard  at  that  spot,  ceasing  when  the  chin  was  again  depressed.  The 
lungs  did  not  appear  to  be  emphysematous,  nor  was  there  any  dulness  at 
either  apex  ;  but  the  breath-sounds  were  very  loud  and  hollow  at  the  su- 
pra-spinous  fossse,  especially  in  expiration. 

There  can  be  little  doubt  that  this  child  was  suffering  from  enlarge- 
ment of  the  bronchial  glands.  The  character  of  the  attacks,  accompanied 
by  hoarseness  of  the  voice,  the  bleeding  from  the  nose,  the  fulness  of 
the  jugular  in  the  neck  and  of  the  superficial  veins  of  the  chest,  the 
hoUow  breathing  at  the  apices  without  sign  of  disease  of  Itmg,  and  the 
venous  hum  heard  at  the  upper  part  of  the  sternum  when  the  head  was 
retracted — indicating  some  pressure  set  up  in  that  position  upon  the  left 
innominate  vein— all  these  signs  were  very  suggestive  of  glandular  enlarge- 
ment. The  child  had  a  scrofulous  appearance  and  was  living  in  a  cold, 
damp  situation.  She  was  treated  with  iodide  of  iron  and  cod-liver  oil,  and 
was  sent  to  pass  the  winter  at  Bournemouth,  whence  she  returned  greatly 
improved. 

This  subject  of  glandular  enlargement  in  the  mediastinum  has  been 
already  considered  in  another  j)lace.  The  reader  is  therefore  referred  to 
the  chapter  on  scrofula  for  fuller  details  with  regard  to  the  phenomena 
produced  by  the  lesion  and  the  signs  by  which  its  presence  may  be  ascer- 
tained (see  pages  182  and  183). 

The  intrusion  of  a  foreign  substance  into  the  bronchus  is  sometimes  a 
cause  of  paroxysmal  dyspnoea.  This  accident  may  be  suspected  if  a  first 
attack  come  on  quite  suddenly  at  or  shortly  after  a  aneal,  or  under  circum- 
stances which  justify  the  assumption,  as  when  a  child  is  playing  with  small 
objects  which  might  readily  slip  into  the  larynx.  In  such  a  case,  if  the  ob- 
ject be  a  small  one,  the  breathing  is  not  always  affected  at  once ;  and  if 
some  cough  and  discomfort  are  excited  at  the  first,  these  symptoms  almost 
invariably  subside,  to  return  after  a  longer  or  shorter  interval.  Professor 
Henoch  has  repoi'ted  the  case  of  a  girl,  aged  nine  years,  who  went  to  bed 
apparently  in  good  health,  but  was  restless,  complaining  of  discomfort 
during  the  night.  Towards  the  morning  she  was  seized  with  extreme  dysp- 
noea and  cyanosis.  The  child  was  taken  to  the  hospital,  where  no  signs 
of  pulmonary  disease  could  be  detected.  Shortly  after  her  return  home 
she  began  to  vomit  large  quantities  of  undigested  food,  amongst  which 
were  found  pieces  of  a  hard-boiled  egg  which  she  had  hiirriedly  swallowed 
on  the  previous  evening.  When  the  vomiting  had  subsided  the  girl  had  a 
good  night's  rest  and  the  dyspnoea  did  not  return.  In  this  case  Dr.  Henoch 
attributed  the  dyspnoea  to  irritation  of  the  gastric  filaments  of  the  vagus  ; 
but  it  seems  more  probable,  as  Dr.  Birkart  has  suggested,  that  the  symp- 
toms were  due  to  actual  bronchial  obstruction  by  a  portion  of  the  imper- 
fectly masticated  food.  The  ordinary  symptoms  produced  by  the  presence 
in  the  air-tubes  of  a  foreign  substance,  and  the  means  by  which  the  cause 
of  the  dyspnoea  may  be  recognised,  are  treated  of  more  fully  in  another 
chapter  (see  page  527). 

The  diagnosis  of  bronchial  asthma  has  usually  to  be  made  by  exclu- 
sion, no  other  cause  being  found  to  which  the  access  of  dyspnoea  can  be 
attributed.  When  called  to  a  child  who  is  said  to  be  suffering  from 
attacks  of  severe  dyspnoea,  unaccompanied  by  laryngeal  stridor,  we  should 
first  of  all  suspect  the  presence  of  enlarged  bronchial  glands.  If  the  most 
careful  examination  fails  to  detect  the  existence  of  any  such  lesion  ;  if  we 
find  that  in  the  interval  of  such  attacks  the  child  is  well  and  hearty,  with- 
out albuminuria  or  sign  of  disease  of  the  heart  ;  that  the  seizures  came  on 
under  the  influence  of  a  pulmonary  catarrh  ;  and  that  the  only  physical 


524  DISEASE   IlSr   CHILDEElSr. 

signs  discoverable  consist  in  a  certain  liyper-resonance  of  the  percussion- 
note  "with  an  occasional  click  or  coo  of  rhonchus,  we  may  conclude  that 
we  have  to  do  with  a  case  of  bronchial  asthma. 

Prognosis. — If  the  child  be  in  such  a  position  in  hfe  that  proper  meas- 
ures can  be  taken  for  his  rehef,  his  prospects  are  not  unfavourable.  If  he 
can  be  sent  away  to  a  proper  climate,  be  warmly  dressed  and  carefully 
attended  to,  dyspnoea  from  enlarged  bronchial  glands  or  from  bronchial 
asthma  is  usually  recovered  fi'om.  The  most  serious  forms  of  paroxysmal 
dyspnoea  are  those  which  result  from  the  presence  of  a  foreign  body  in 
the  air-passages  ;  from  interstitial  pulmonary  oedema  in  Bright's  disease  ; 
and  from  clotting  in  the  pulmonary  artery.  In  the  last  of  these,  few  cases 
recover.  In  the  case  of  Bright's  disease  when  the  illness  is  of  the  acute 
form,  T>'e  may  have  hopes  that  if  the  immediate  danger  can  be  tided  over, 
the  child  may  eventually  recover.  If  the  renal  mischief  be  chronic,  the 
prognosis  is  very  unfavourable.  When  the  dyspnoea  is  due  to  the  entrance 
of  a  foreign  body  into  the  ah--passages,  the  prognosis  is  given  elsewhere 
(see  page  533). 

Treatment. — If  the  child  be  first  seen  during  an  attack  we  are  forced 
to  treat  the  dyspnoea  without  reference  to  its  cause.  Strong  mustard 
poultice  should  be  applied  to  the  chest  and  moved  about  from  one  place 
to  another  over  the  front  and  back  of  the  thorax.  Secretion  should  be 
promoted  by  giving  hot  liquids  to  di'ink  ;  and  a  very  useful  form  is  that 
composed  of  a  dessert-spoonful  of  liq.  ammoniee  acetatis,  diluted  with  three 
or  four  times  its  bulk  of  hot  water.  Trousseau  recommends  the  burning 
of  stramonium  leaves  in  the  room  ;  but  this  is  a  \erj  uncertain  remedy 
and  has  lately  fallen  out  of  favour  in  the  case  of  the  adult.  The  fumes  of 
nitre  jDaper  are  preferred  by  some.  Enough  should  be  used  to  make  the 
atmosphere  thick  with  the  nitrous  vajDour.  If  w^e  can  discover  that  the 
child  has  lately  swallowed  some  indigestible  food  or  notice  any  undue 
distention  of  the  abdomen,  it  will  be  well  to  reheve  the  stomach  by  an 
emetic  dose  of  ipecacuanha  wine. 

When  the  attack  of  dyspnoea  has  subsided  or  the  respiration  has 
become  easier,  we  shall  be  probably  able  to  examine  the  patient  sufficient- 
ly to  form  an  opinion  as  to  the  cause  of  the  distress  in  breathing.  When 
the  dyspnoea  is  due  to  enlargement  of  the  bronchial  glands,  or  to  any  of 
the  less  common  causes  which  have  been  mentioned,  the  general  treatment 
to  be  pursued  is  described  in  other  parts  of  this  treatise. 

If  the  case  be  one  of  bronchial  asthma  the  child  is  almost  invariably 
the  subject  of  pulmonary  emphysema,  and  the  treatment  recommended 
for  that  condition  of  the  lung  should  be  scrupulously  earned  out.  All 
means  which  invigorate  the  general  health  are  useful,  and  cod-liver  -oil 
with  iron,  especially  the  iodide  of  iron,  should  be  prescribed.  Fowler's  solu- 
tion of  arsenic  is  also  often  of  service,  especially  in  cases  where  the  asth- 
matic symptoms  are  associated  with  eczema  of  the  scalp  or  other  part  of 
the  body.  Dr.  Thorowgood  advocates  the  use  of  a  tonic  during  the  day, 
and  recommends  a  sedative  at  night,  such  as  a  dose  of  the  extract  of 
stramonium  or  tincture  of  belladonna.  Thus,  a  child  of  six  years  old  may 
take  thi'ee  or  four  drops  of  the  hq.  arsenicalis  with  ten  of  the  tincttu'e  of 
perchloride  of  iron  fi'eely  diluted  after  each  meal,  and  on  going  to  bed 
twenty  to  thirty  drops  of  the  tincture  of  belladonna. 

The  hypodermic  injection  of  pilocai-pine  may  be  used  in  these  cases,  as 
dh-ected  by  Dr.  Berkart.  Children  bear  this  remedy  well.  For  a  child  of 
five  years  old,  gr.  J^j-  to  gr.  ^  may  be  injected  under  the  skin  when  the  child 
is  put  to  bed.     In  the  daytime  the  arsenic  and  iron  can  be  continued. 


PAROXYSMAL   DY8PN(EA — TREATMENT.  525 

When  the  attacks  of  dyspnoea  come  on  chiefly  at  night,  the  child  should 
be  forbidden  to  eat  heartily  in  the  latter  part  of  the  day,  and  should  by 
no  means  be  permitted  to  go  to  bed  shortly  after  a  full  meal.  Indeed,  care 
should  be  taken  at  every  meal  that  the  stomach  is  not  overloaded,  and  Dr. 
Thorowgood's  caution  that  moderation  should  be  exercised  in  the  use  of 
farinaceous  and  saccharine  articles  is  especially  wise  in  the  case  of  a  child. 

The  whole  secret  of  the  treatment  of  these  cases  consists  in  employing 
all  available  measures  for  improving  the  general  strength  and  in  guarding 
the  patient  carefully  from  chills.  Exercise,  gymnastics,  and  games  which 
further  the  development  of  the  muscles  and  promote  the  action  of  the  skin 
are  all  very  useful. 


CHAPTER  XIV. 

FOREIGN  BODIES  IX  THE  AIR-TUBES. 

The  passage  of  solid  substances  into  the  aii'-tubes  is  a  far  fi'om  uncommon 
accident  and  one  to  which  children,  for  obvious  reasons,  are  pecuharly 
liable.  Articles  of  the  most  varied  description  have  been  inadvertently- 
drawn  into  the  trachea,  and  theii'  retention  in  the  bronchi  may  not  only 
produce  the  most  serious  distress  but  set  up  profound  disorganization  in 
the  affected  lung. 

Fruit-stones,  as  might  be  expected,  ai'e  perhajDS  the  commonest  things 
to  make  their  way  into  the  trachea  ;  also  peas,  beans,  grains  of  com,  vari- 
ous seeds,  bits  of  sohd  food,  fish-bones,  portions  of  nut-shell,  and  any 
small  articles  which  he  about  in  a  room  or  can  be  picked  up  from  the  floor, 
such  as  little  coins,  tin  tacks,  dress -hooks,  buttons — all  of  these  objects, 
and  many  others,  have  been  known  to  pass  between  the  vocal  cords  and 
be  imprisoned  in  a  bronchus.  It  is  at  fh'st  difficult  to  understand  how  a 
substance  as  large  as  a  plum-  or  date-stone  can  pass  through  the  narrow 
ajDertiu-e  formed  by  the  vocal  cords  in  a  young  child.  It  must  be  remem- 
bered, however,  that  when  the  chest-walls  are  expanded  in  the  act  of  inspi- 
ration, if  a  solid  body  is  drawn  into  the  opening,  a  very  strong  pressure 
fi'om  the  external  atmosphere  forces  it  onwards,  while  resistance  is  very 
trifling  on  account  of  the  tendency  to  form  a  vacuum  inside  the  chest. 
Consequently,  the  substance  is  driven  through  the  opening  with  consider- 
able force. 

Morbid  Anatomy. — The  morbid  changes  which  result  from  the  presence 
'  of  a  foreign  substance  in  the  au'-passages  are  often  very  extensive.  The 
immediate  consequences  are  congestion  and  irritation  of  the  mucous  mem- 
brane lining  the  trachea,  and  if  the  substance  is  small  enough  to  penetrate 
into  them,  of  the  bronchi.  Secretion  then  takes  place  of  a  thin  frothy 
fluid  which  soon  becomes  purulent,  and  may  be  so  profuse  that  after  death 
the  air-tubes  are  found  filled  with  yeUow  puriform  matter.  Thick  lymph 
may  be  also  throT^^l  out  so  as  partly  to  coat  the  obstiaiction.  In  a  case  re- 
corded by  ]Mi'.  Bullock  the  lymph  became  organized  into  fibiinous  casts 
and  almost  closed  the  upper  portion  of  the  windpipe.  The  muco-pus  is 
thick  and  ropy  and  in  long-standing  cases  may  be  inexpressibly  fetid. 

A  substance  capable  of  passing  into  the  larger  bronchi  soon  sets  up 
inflammation  in  the  lung.  The  inflammation  may  be  limited  to  one  lobe 
or  may  spread  to  the  entire  organ.  Sometimes  both  lungs  are  affected 
simultaneously,  owing  to  the  offending  substance  being  dislodged  by  the 
repeated  cough  and  falling  back  into  one  or  the  other  bronchus  indisciim- 
inately.  The  affected  j^art  becomes. consolidated,  and  if  the  ii-ritation  per- 
sist, soon  disintegrates  and  breaks  down.  Ca-^ities  are  thus  produced 
which  are  filled  with  offensive  and  even  gangTenous  debris  and  much  piuii- 
lent  matter.  If  there  be  no  sufficient  communication  with  an  air-passage, 
the  contents  may  be  retained;. but  usuaUy  an  opening  becomes  estabHshecl 


F0REIG:N"  bodies  IX  the  AIE-TTJBES — SYMPTOMS.  527 

with  the  bronchus  and  much  fetid  matter  is  expectorated.  In  scrofulous 
or  tubercular  subjects  gi-ay  granulations  may  be  developed  in  the  hepatized 
tissue  around  the  cavity,  and  it  has  happened  that  the  child  has  died  from 
general  tuberculosis.  The  bronchial  glands  also  become  enlarged  and 
cheesy. 

Besides  pneumonia,  other  pulmonary  lesions  may  be  present.  More  or 
less  emphysema  is  usually  produced,  and  collapse  of  portions  of  the  lung 
may  occiu\  The  inflammatory  action  may  not  be  confined  to  the  lung. 
Empyema  is  a  common  consequence  of  the  presence  of  the  iiTitant ;  and 
enormous  quantities  of  punxLent  fluid  have  been  found  distending  the 
pleui'al  canity.  Pericarditis  has  also  been  known  to  occur,  and  in  a  case 
recorded  by  Mr.  Solly  a  large  abscess  had  fonned  in  the  mediastinum  as  a 
consequence  of  the  jDericardial  inflammation.  Sometimes  the  abscess  of  the 
lung  becomes  adherent  to  the  chest-wall  and  points  in  an  intercostal  space 
or  elsewhere.  Dr.  Wilts  has  referred  to  a  case  in  which  an  ear  of  corn  es- 
caped in  this  manner  fi-om  an  abscess  which  had  formed  in  the  supra- 
scapular region  ;  and  other  cases  of  a  similar  kind  are  on  record. 

Symptoms. — The  initation  produced  by  the  entrance  of  a  foreign  body 
into  the  trachea  and  bronchi  varies  gTeatly  in  different  patients.  Although 
in  the  majority  of  cases  the  suffering  is  extreme,  in  a  few  instances  curiously 
little  discomfort  appears  to  be  excited.  It  is  important  to  be  aware  that 
violent  dyspnoea  is  not  an  unfaihng  symptom  of  this  accident.  In  some 
recorded  cases  a  httle  cough  has  been  the  only  inconvenience  complained 
of.  Dr.  Goodheart  has  stated  that  on  two  occasions  in  his  experience  in 
which  dissection  revealed  gangi'ene  of  the  king  setup  by  a  spicula  of  bone 
in  one  of  the  bronchi  no  symptoms  had  been  noted  during  hfe  pointing  to 
the  entrance  of  a  foreign  substance  into  the  aii'-tubes  ;  and  thence  con- 
cludes that  pulmonary  disease  is  more  often  excited  by  this  mischance  than 
is  commonly  supposed. 

Still,  although  in  exceptional  cases  the  suffering  may  be  slight,  as  a 
rule  the  intrusion  of  any  adventitious  matter  into  the  wind-j^ipe  is  a  cause 
of  immediate  and  extreme  distress.  If  the  substance  be  of  large  size  it  may 
completely  occlude  the  glottis  and  cause  sudden  death.  Many  cases  are 
on  record  in  which  the  entrance  of  the  wind-pipe  has  been  blocked  up  by 
a  lump  of  food  with  immediately  fatal  results.  Smaller  bodies  which  can 
pass  readily  into  the  aii'-tubes,  if  not  an-ested  at  the  bifurcation  of  the  tra- 
chea, fall  as  a  rule  into  the  right  bronchus.  iVIr.  Goodall  of  Dublin  pointed 
out  many  years  ago  that  the  septum  of  the  division  of  the  windpipe  is 
placed  considerably  to  the  left  of  the  mesial  line,  and  that  this  x^osition 
tends  to  deflect  any  substance  falling  against  it  into  the  light  division  of 
the  ah'-tube. 

The  first  consequence  of  the  accident  is  usually  a  fit  of  severe  dyspnoea 
with  sense  of  impending  suffocation.  The  child  shows  all  the  symptoms 
of  the  most  extreme  distress.  His  eyes  look  wild  ;  his  face  is  hvid  ;  his 
nares  work  ;  his  chest  heaves  convulsively  ;  he  tears  with  his  hand  at  his 
thi-oat,  and  bursts  into  a  paroxysm  of  spasmodic  cough.  As  a  inile  ex- 
piration seems  more  difficult  than  inspii'ation,  and  the  effort  to  discharge 
air  from  the  lungs  is  laborious  and  painful.  In  some  cases  foam  tinged 
with  blood  ax^pears  at  the  lij^s.  The  early  symptoms  are  more  severe  if 
the  object  lodges  sufficiently  near  to  the  glottis  to  keep  up  irritation  of 
the  vocal  cords.  The  attacks  of  spasmodic  cough  are  then  almost  inces- 
sant and  the  difficulty  of  breathing  extreme.  In  ordinary  cases  after  some 
minutes  the  more  urgent  symptoms  abate  and  may  entirely  subside,  so 
that  the  child  who  a  short  time  before  had  seemed  on  the  very  poiat  of 


528  DISEASE   IN   CHILDEEN. 

suffocation  returns  to  his  play  as  if  nothing  had  happened ;  but  after  a 
period  of  calm  the  paroxysms  usually  return  with  more  or  less  violence. 
The  period  of  repose  which  follows  the  first  access  of  dyspnoea  is  of  very 
variable  duration.  It  may  last  from  a  few  minutes  to  several  hours  ;  and 
cases  have  been  published  in  which  no  return  of  the  distress  was  experi- 
enced for  many  months.  The  degree  of  suffering  in  these  cases,  accord- 
ing to  Dr.  Stokes,  is  dependent  to  a  considerable  extent  upon  the  com- 
pleteness with  which  the  intruding  body  interferes  with  the  passage  of  air 
through  the  tube.  He  states  that  in  all  cases  which  have  come  under  his 
own  observation  the  distress  was  great  in  proportion  to  the  feebleness  of 
respiratory  mui-mur  in  the  affected  lung.  A  smooth  body,  therefore,  such 
as  a  bean,  by  completely  occluding  the  tube  causes  greater  suffering  than 
a  more  irregular  substance  will  do  ;  for  the  latter,  although  it  obstructs 
the  passage,  does  not  render  it  absolutely  impermeable. 

Often  in  addition  to  recurring  attacks  of  dyspnoea  and  spasmodic 
cough  there  is  a  fixed  pain  or  soreness  referred  to  the  throat  or  some  part 
of  the  chest,  back,  or  side.  This  sensation  is  probably  dependent  upon 
the  impaction  of  the  intruding  substance  in  some  particular  part  of  the 
bronchus,  for  it  has  been  known  suddenly  to  shift  its  place,  passing  from 
the  throat  to  the  chest  or  to  the  region  of  the  nipple.  In  some  cases  the 
pain  is  accompanied  by  a  sense  of  constriction.  Often,  also,  there  is  ina- 
bility to  lie  on  one  or  the  other  side,  such  a  position  increasing  the  uneasy 
feeling  and  impeding  the  respiration.  Sometimes  the  child  can  only 
breathe  with  ease  in  the  sitting  position,  and  has  to  be  propped  up  in  bed 
with  pillows.  The  fits  of  coughing  are  of  a  peculiar  character.  They  are 
usually  excessively  spasmodic  and  often  resemble  the  cough  of  pertussis. 
They  are  accompanied  by  much  congestion  and  lividity  of  the  face,  but 
are  not  followed  by  attempts  to  vomit.  Sometimes  the  paroxysms  are  so 
violent  as  to  lead  to  a  convulsive  seizure.  If  the  object  introduced  is  a 
fruit-stone  or  similar  solid  substance,  and  is  free  to  move  in  the  air-pas- 
sages, the  cough  may  be  accompanied  by  a  peculiar  clicking  or  flapping 
noise  heard  in  the  direction  of  the  larynx,  and  produced  apparently  by 
the  impact  of  the  object  driven  upwards  against  the  glottis  by  the  current 
of  air.  In  many  cases  the  impact  may  be  felt  as  well  as  heard  if  the  finger 
and  thumb  be  applied  during  the  cough  to  opposite  sides  of  the  larynx. 

The  voice  may  be  unaltered  luiless  the  object  be  arrested  in  the  neigh- 
bourhood of  the  glottis,  as  in  one  of  the  ventricles  of  the  larynx,  in  which 
case  there  may  be  any  degree  of  hoarseness  even  to  complete  aphonia. 

On  inspection  of  the  chest  considerable  recession  of  the  soft  parts  is 
usually  to  be  noticed  in  inspiration,  and-  there  may  be  a  swelling  of  the 
neck  and  upper  part  of  the  chest  from  surgical  emphysema.  Often  a  phy- 
sical examination  at  an  early  period  detects  little  or  no  deviation  from  a 
healthy  state.  There  may  be  perfect  resonance ;  the  respiration  may  be 
normal,  and  nothing  may  be  heard  but  a  little  sonorous  or  sibilant  rhon- 
chus  over  the  lung  in  connection  with  the  occluded  bronchus.  If  the 
foreign  substance  be  impacted  and  immovable  in  the  air-tube,  signs  of 
collapse  may  be  noticed  at  some  part  of  the  lung  a  few  days  after  the  ac- 
cident ;  or  there  may  be  absolute  suppression  of  the  respiratory  murmur 
over  the  whole  of  the  affected  side. 

Whenever  irritation  is  excited  in  the  air-passages  there  is  fever,  and 
the  general  health  of  the  child  necessarily  suffers  from  the  constant  dis- 
tress and  interference  with  sleep.  Food  can,  however,  be  taken  without 
difficulty. 

In'  some  cases  after  a  few  hours  or  a  day  or  two  a  spontaneous  expul-- 


FOREIGN   BODIES   IN   THE   AIR-TUBES — SYMPTOMS.  529 

sion  of  the  offending  substance  takes  place  during  a  fit  of  coughing  and 
the  patient  is  instantly  relieved.  If,  however,  the  child  is  less  fortunate 
and  the  foreign  body  remains  in  the  tubes,  its  presence  being  unknown  or 
efforts  to  procure  its  removal  having  proved  fruitless,  serious  consequences 
ensue.  The  object  may  become  impacted  in  the  larynx,  causing  death  by 
suffocation  ;  it  may  set  up  a  violent  catarrhal  pneumonia  and  the  patient 
may  quickly  die  ;  it  may  give  rise  to  suppuration  and  gangrene  ;  or  it  may 
lead  to  chronic  phthisis  which  ends  fatally  after  a  more  or  less  lingering 
illness. 

Spontaneous  expulsion  usually  takes  place,  as  has  been  said,  during  a 
violent  fit  of  coughing.  It  may  occur  after  a  short  or  a  long  interval ;  and 
in  some  cases  a  period  of  years  has  elapsed  before  the  offending  substance 
has  been  ejected.  The  completeness  of  recovery  in  such  cases  depends 
upon  the  degree  to  which  the  lung  has  suffered  from  the  presence  of  the 
intruder.  If  the  foreign  body  have  only  given  rise  to  irritation  in  the  lung, 
its  removal  is  followed  by  instant  and  permanent  relief.  If,  however,  pneu- 
monia have  been  set  up,  or  an  abscess  have  formed,  or  chronic  phthisical 
changes  have  been  induced,  the  patient  may  die,  although  the  original 
cause  of  his  suffering  has  disappeared. 

In  cases  where  the  foreign  body  remains  in  the  tubes,  a  constant  source 
of  irritation  and  of  interference  with  the  function'  of  the  affected  organ,  the 
physical  signs  depend  upon  the  form  of  lesion  which  is  produced.  In  some 
cases  profound  disorganization  of  the  lung  follows,  and  extra-costal  sup- 
puration may  be  set  up  leading  to  the  formation  of  a  large  superficial  ab- 
scess. 

A  little  boy,  aged  seven  years,  whose  family  history  showed  no  tendency 
to  phthisis,  was  in  his  usual  health  when,  on  March  28th,  he  returned  from 
school  saying  he  had  swallowed  a  date-stone.  He  complained  of  difficulty  of 
breathing  and  pain  in  the  side,  and  coughed  a  great  deal.  The  symptoms 
apparently  were  not  very  severe,  for  the  child  was  only  brought  to  the  hos- 
pital on  April  8th.  On  his  admission  it  was  noted  :  "Much  recession  of 
the  lower  parts  of  the  chest  on  inspiration  ;  intercostal  spaces  move  equally 
on  the  two  sides.  Resonance  good  over  both  sides,  but  on  the  left  the  inspi- 
ration is  everywhere  high-pitched  and  bronchial,  and  is  as  loud  below  as 
above.  No  rhonchus  or  friction.  Heart's  apex  between  the  fifth  and  sixth 
ribs  just  outside  the  nipple  line.  A  faint  double  friction-sound  at  the  base 
of  the  heart  and  a  soft  systolic  murmur  at  the  apex." 

At  this  time  nothing  was  known  of  the  accident ;  and  as  there  was  but 
little  oppression  of  breathing  and  the  cough  soon  after  admission  was  found 
to  be  spasmodic,  the  boy  was  thought  to  be  developing  whooping-cough, 
and  was  sent  out  by  the  House  Surgeon. 

On  April  22d,  the  child  was  brought  back  to  the  hospital  with  a  full 
account  of  the  origin  of  the  illness.  It  was  stated  that  after  his  discharge 
he  had  continued  to  cough  in  a  spasmodic  manner  and  to  whoop  occasion- 
ally. He  had  often  complained  of  pain  in  his  stomach  and  left  side  and 
his  breathing  had  been  oppressed.  He  had  little  appetite.  His  skim  had 
been  hot  with  occasional  perspirations.  Shortly  before  his  return  to  the 
hospital  the  aspirator  had  been  used  to  the  chest  by  a  practitioner  of  the 
neighbourhood,  but  no  fluid  had  escaped. 

The  boy  appeared  to  be  excessively  ill.  He  complained  much  of  pain 
in  the  abdomen  and  lay  with  his  knees  drawn  up.  The  abdominal  pari- 
etes  were  somewhat  retracted.  Over  the  left  back  reaching  from  the  poste- 
rior axillary  line  nearly  to  the  spine,  and  from  a  little  above  the  lower 
angle  of  the  scapula  to  the  tenth  rib,  was  a  large  sujDerficial  collection  of 
34 


530  DISEASE  IlSr   CHILDEEN. 

matter.  This  on  being  oj^ened  was  found  to  consist  of  very  offensive, pus. 
The  abscess  evidently  communicated  with  the  pleural  cavity,  for  air  was 
sucked  in  through  the  wound  at  each  inspiration.  The  boy's  breathing 
was  laboiu-ed  and  his  voice  whispering.  An  examination  of  the  chest  was 
difficult  on  account  of  the  tenderness  of  the  side.  It  was  however,  ascer- 
tained that  resonance  of  the  left  back,  although  impaired,  was  not  quite 
lost,  and  that  the  respiratory  sounds  were  concealed  by  loud  creaking  and 
gurghng  rhonchus. 

The  boy  remained  very  prostrate  and  in  great  distress.  He  was  exces- 
sively restless  and  occasionally  screamed  in  a  very  hoarse  voice.  The 
discharge  fi-om  the  wound  was  inexpressibly  fetid.  He  died  on  April 
25th.     His  temperature  after  readmission  varied  between  100°  and  102.4°. 

On  examination  of  the  body,  seventeen  hours  after  death,  the  super- 
ficial abscess  cavity  was  found  to  extend  from  the  middle  line  of  the  right 
clavicle  across  the  chest  and  round  the  left  side  to  the  spine.  The  skin 
over  it  was  sodden  and  seemed  almost  decomposed.  The  body  was  much 
emaciated.  On  opening  the  chest  the  right  lung  was  generally  adherent 
to  the  chest-wall,  although  not  very  firmly.  Its  substance  was  somewhat 
congested  but  otherwise  normal.  The  bronchi  were  injected  and  their 
mucous  lining  cedematous. 

The  left  lung,  firmly  adherent  on  its  posterior  surface,  was  extensively 
disorganized.  Its  substance  tore  easily  and  the  smell  was  almost  insup- 
portable. The  surface  of  the  diaphragm  had  the  appearance  of  an  abscess. 
In  the  eighth  interspace,  about  one  inch  behind  the  posterior  axillary  hne, 
was  a  large  ulcerated  depression  rather  more  than  an  inch  in  diameter, 
at  the  bottom  of  which  was  a  j)erforation  communicating  through  the 
intercostal  space  with  the  superficial  abscess.  The  trachea  was  injected, 
and  in  the  left  bronchus  was  a  date-stone  impacted  about  an  inch  and  a 
half  from  the  bifurcation.  The  lining  membrane  of  the  bronchus  was  red 
and  cedematous,  but  the  air-passages  contained  no  excess  of  fluid.  On 
account  of  the  disorganized  state  of  the  lung  it  was  impossible  to  say 
whether  an  abscess  had  originally  formed  in  the  neighbourhood  of  the 
date-stone.  There  was  no  peritonitis.  The  left  ventricle  of  the  heart 
was  hypertrophied,  and  the  edges  of  the  mitral  valve  were  much  thick- 
ened. 

This  case  is  peculiar  on  account  of  the  situation  of  the  foreign  body, 
which  had  passed  into  the  left  bronchus  instead  of  the  right.  "When  the 
child  was  first  brought  to  the  hospital  no  mention  was  made  of  liis  acci- 
dent, and  nothing  in  his  symptoms  suggested  the  presence  of  a  solid 
substance  in  his  lung.  There  was  no  great  distress  of  breathing,  and  the 
physical  signs,  such  as  they  were,  were  hmited  to  the  left  lung,  the  right 
side  of  the  chest  being  healthy. 

The  foreign  body  after  passing  the  rima  glottidis  may  be  caught  in 
one  of  the  ventricles  of  the  larynx  ;  it  may  become  fixed  in  the  trachea  ; 
or  may  pass  further  down  and  lodge  in  one  of  the  primary  divisions  of  the 
au'-tube.  There  are,  therefore,  certain  varieties  in  the  symptoms  according 
to  the  position  of  the  obstruction. 

If  the  solid  substance  remain  in  the  larjTix,  the  voice  is  suppressed ; 
the  dyspnoea  is  continuous  ;  the  cough  is  generally  violent  and  croupy  ; 
the  child  feels  as  if  he  should  choke  ;  and  there  is  often  pain  referred  to 
the  situation  of  the  cricoid  cartilage.  It  may,  however,  be  remai'ked  that 
aphonia  is  not  limited  to  these  cases,  and  that  a  hoarse  whispering  voice 
does  not  necessarily  indicate  that  the  obstacle  is  fixed  in  the  larynx.  In 
the  case  just  narrated,  although  the  fi'uit-stone  was  impacted  in  the  left 


FOEEI&N   BODIES   IN  THE   AIE-TXJBES — SYMPTOMS.  531 

bronchus  and  the  larynx  was  free,  the  voice  was  hoarse  and  almost  sup- 
pressed. 

If  the  substance  lodge  in  the  trachea  below  the  larynx,  the  suffering 
produced  is  not  very  great,  as  a  rule,  so  long  as  the  passage  remains 
pervious.  In  the  often-quoted  case  related  by  Mr.  McNamara  of  Dublin, 
in  which  a  boy  who  had  constructed  a  whistle  out  of  a  plum-stone,  inad- 
vertently drew  the  toy  by  a  strong  inspiration  through  the  glottis,  the 
object  remained  fixed  transversely  in  the  lower  part  of  the  larynx,  and 
gave  rise  to  a  whistling  sound  as  the  air  passed  through  it  in  expiration. 
The  only  inconvenience  produced  by  the  accident  while  the  obstacle  re- 
mained in  this  situation  was  an  occasional  suffocative  cough  ;  but  this  did 
not  prevent  the  boy  from  running  about  and  playing  as  usual. 

In  the  bronchus  the  symptoms  produced  by  the  presence  of  a  foreign 
body  vary  according  as  this  is  fixed  or  is  free  to  move.  If  a  smooth  sub- 
stance, such  as  a  fruit-stone,  become  fixed  in  the  bronchus,  it  causes  great 
distress  by  plugging  the  air-tube  and  arresting  the  function  of  the  corre- 
sponding lung.  The  air  cannot  enter  or  escape.  Consequently  the  patient 
experiences  great  dyspnoea  from  sudden  loss  of  half  his  breathing  surface. 
He  has  attacks  of  spasmodic  cough  from  the  irritation  induced  at  the  seat 
of  obstruction,  and  on  the  affected  side  the  vesicular  murmur  is  weakened 
or  suppressed.  Catarrhal  pneumonia  in  this  case  follows  very  quickly. 
If  the  impacted  body  be  irregular  in  shape,  so  as  still  to  allow  the  passage 
of  air  through  the  tube,  there  is  less  opj^ression  of  breathing,  and  in  many 
cases  less  irritation  in  the  lung  ;  also,  the  pathological  results  are  more 
chronic  in  their  course. 

If  the  intruding  substance  be  free  to  move,  as  is  sometimes  the  case 
with  a  rounded  body  which  does  not  so  readily  become  impacted. in  the 
air-tube,  very  curious  consequences  follow.  When  the  object  is  carried 
against  or  into  the  larynx,  it  produces  spasmodic  cough  and  an  agonizing 
feeling  of  suffocation.  As  it  descends  again  into  the  lower  tube  there 
succeeds  a  period  of  comparative  calm  ;  and  the  physical  signs  which  have 
been  described  as  indicating  impaction  of  the  substance  in  the  bronchus 
may  perhaps  be  noticed.  This  alternation  of  suffocative  cough  with 
intervals  of  more  or  less  complete  repose  are  very  characteristic.  It  is  in 
these  cases  that  the  presence  of  the  foreign  body  can  sometimes  be  detected 
by  the  ear  and  the  touch.  In  the  case  of  a  little  girl,  aged  two  years,  who 
was  under  my  care  in  the  East  London  Children's  Hospital  suffering  from 
the  presence  of  a  haricot  bean  in  the  air-tubes,  the  physical  signs  noted 
by  the  House  Surgeon,  Mr.  Scott  Battams,  on  the  evening  of  the  day  on 
which  the  accident  happened  were  :  ' '  Air  enters  fairly  well  into  both 
sides  of  the  chest.  At  the  apices  expiration  is  prolonged  and  wheezing. 
On  listening  at  the  middle  of  the  right  back  a  sound  is  heard  as  if  a  solid 
body  were  drawn  down  in  inspiration  and  carried  away  again  in  a  forced 
expiration."  The  child,  although  not  much  troubled  by  dyspnoea,  suffered 
greatly  from  cough  ;  and  when  this  was  violent  the  finger  and  thumb 
placed  on  either  side  of  the  upper  part  of  the  trachea  could  feel  a  distinct 
impact  as  of  some  solid  body  striking  this  part  of  the  tube  with  each  im- 
pulse of  cough.  Afterwards  with  the  stethoscope  placed  upon  the  same 
part  a  dull  thud-like  sound  was  distinctly  audible  as  the  object  was  forced 
upwards  by  the  current  of  air. 

Diagnosis. — Whenever  a  foreign  body  has  passed  into  the  windpipe  it 
is  of  the  utmost  importance  to  the  patient  that  there  should  be  no  mystery 
as  to  the  cause  of  his  symptoms,  for  recovery  will  probably  depend  upon 
ready  measures  being  taken  for  the  expulsion  of  the  offending  substance. 


532  DISEASE  IN   CHILD RElSr. 

The  diagnosis  rests  upon  the  history  of  the  accident  and  the  sudden  occur- 
rence of  the  symptoms  in  a  child  previously  healthy ;  also,  upon  the  nature 
and  situation  of  the  physical  signs  to  be  discovered  on  examination  of  the 
chest. 

-  The  history  is  not  always  to  be  obtained.  Thus,  in  the  case  of  a  baby, 
unless  the  child  have  been  seen  to  play  with  some  small  object  immediately 
before  the  suffocative  attack  occurred,  the  likelihood  of  a  foreign  body  hav- 
ing passed  into  the  trachea  may  not  even  be  entertained.  Again,  the  his- 
tory may  be  misleading.  Attacks  of  spasmodic  laryngitis  may  occur  in  a 
young  child  while  at  play  ;  and  if  any  small  objects  hkely  to  produce  such 
symptoms  are  found  within  his  reach,  the  inference  that  a  similar  object 
has  been  introduced  into  the  air-passage  is  sufficiently  obvious.  If  the 
attack  of  laryngitis  occurred  first  under  such  circumstances,  this  inference 
would  be  almost  unavoidable.  Still,  although  not  necessaiily  conclusive, 
a  history  of  the  probable  introduction  of  a  solid  substance  into  the  wind- 
pipe is  of  great  value.  If  a  child  while  in  his  usual  health  has  been  eating 
stoned  fruit,  or  playing  with  small  articles  such  as  peas,  haricot  beans,  or 
grains  of  corn,  and  is  seized  all  at  once  with  violent  oppression  of  breath- 
ing and  spasmodic  cough,  we  shovdd  consider  very  carefully  the  evidence 
to  be  obtained  from  a  physical  examination  of  the  chest.  It  must  be  re- 
membered that  the  first  distress  is  only  temporary,  and  is  suceeeded  by  a 
period  of  calm,  of  variable  duration.  When  called  to  such  a  case,  there- 
fore, we  must  not  conclude  because  the  child's  suffering  has  subsided  that 
all  danger  is  at  an  end. 

The  physical  signs  in  these  cases  may  be  indicative  of  pulmonary  irrita- 
tion or  of  more  or  less  complete  obstruction  of  a  bronchus.  The  irritation 
set  up  in  the  air-tube  leads  quickly  to  increased  secretion,  so  that  more  or 
less  sibilant  or  sonorous  rhonchus  and  bubbling  rales  are  usuaUy  heard 
with  the  stethoscope.  If  in  a  case  where  the  symptoms  occurred  suddenly 
under  circumstances  suggesting  the  introduction  of  a  solid  substance  into 
the  windpipe,  the  above  signs  of  irritation  are  discovered  on  one  side  only, 
and  that  side  the  right  side,  the  evidence  must  be  looked  upon  as  impor- 
tant. 

Signs  of  plugging  of  a  bronchus  are,  however,  of  the  greater  value. 
Comjplete  absence  of  breath-sound  and  of  respiratory  movement  over  the 
whole  of  the  affected  side  v^thout  alteration  in  the  normal  resonance — these 
signs  occurring  suddenly  in  a  child  in  whom  suffocative  cough  began  all  at 
once  in  the  midst  of  perfect  health,  would  be  strong  evidence  of  the  pres- 
ence of  a  foreign  body  in  the  air-tubes,  even  in  the  absence  of  any  history 
pointing  to  such  an  accident.  If  in  such  a  case  violent  suffocative  cough 
breaks  out  again,  and  at  the  same  time  the  morbid  phenomena  disappear 
from  the  chest,  the  vesicular  murmur  returning  with  natural  loudness  on 
the  side  previously  silent,  the  phenomenon  is  very  characteristic.  These 
alternations  of  comparative  calm  and  absence  of  breath-sound  with  violent 
spasmodic  cough  and  perfectly  normal  ph3'sical  signs  may  be  looked  upon 
as  pathognomonic.  If  the  impact  of  the  imprisoned  body  can  be  felt  and 
heard  in  the  trachea  during  the  cough,  the  evidence  thus  furnished  of  the 
presence  of  a  sohd  substance  in  the  air-passages  is  practically  conclusive. 

If  the  tube,  instead  of  being  perfectly  closed  is  partially  permeable,  ap-. 
preciable  weakness  of  the  vesicular  murmur  may  be  noticed  on  the  affected 
side.  Such  a  sign  occurring  alone  may  have  httle  importance  attached  to 
it ;  but  if  with  weak  breathing  over  the  right  lung  we  notice  sonoro-sibi- 
lant  rhonchus  or  bubbling  rales  over  the  upper  part  of  the  same  side,  the 
other  lung  being  healthy,  the  combination  is  of  some  value. 


FOEEIGN   BODIES   IN  THE   AIR-TUBES — TREATMENT.  533 

When  the  foreign  body  remains  in  the  larynx  caught  in  one  of  the  ven- 
tricles, the  resulting  symptoms — aphonia,  dyspncea,  violent  croupy  cough, 
and  sense  of  choking — may  suggest  stridulous  laryngitis  or  membranous 
croup.  In  such  a  case  the  history  of  the  seizure,  especially  the  sudden  oc- 
currence of  the  distress  in  a  child  previously  in  a  state  of  perfect  health, 
is  of  great  importance.  In  stridulous  laryngitis,  although  the  complaint 
often  begins  with  much  violence  and  quite  suddenly,  the  spasm  almost  in- 
variably occurs  at  night,  the  child  starting  from  his  sleep  with  urgent 
dyspnoea ;  and  the  symptoms  subside  completely  after  a  short  time.  In 
the  case  of  a  solid  substance  in  the  larynx  the  access  occurs  while  the  child 
is  awake  and  at  play  ;  the  dyspnoea  is  more  continuous  ;  and  the  remission, 
if  it  occur  while  the  foreign  body  remains  in  the  neighbourhood  of  the 
larynx,  is  far  less  complete. 

In  membranous  croup  the  attacks  of  dyspnoea  come  on  gradually,  and 
slowly  increase  in  severity  ;  the  voice  is  not  whispering  at  the  first ;  and  in 
many  cases  patches  of  false  membrane  may  be  seen  in  the  fauces. 

Prognosis. — If  expulsion  of  the  imprisoned  body  cannot  be  effected, 
the  prognosis  is  very  gloomy ;  for  although  cases  have  been  recorded  in 
which  the  patient  has  continued  for  years  to  suffer  little  from  the  pres- 
ence of  the  solid  substance  in  his  air-passages,  such  cases  are  very  excep- 
tional. Most  commonly  ill  effects  are  not  slow  in  making  themselves  evi- 
dent. The  prognosis  is  more  favourable  if  the  impacted  object  is  of  irreg- 
ular shape,  so  as  to  allow  air  to  pass  and  repass  it  in  the  tube.  In  such 
cases  the  patient  may  escape  rapid  death.  In  almost  all  the  instances  in 
which  chronic  phthisical  changes  have  been  developed  as  a  consequence  of 
the  accident  the  substance  has  been  of  an  irregular  shape. 

If  expulsion  is  effected,  the  prognosis  necessarily  depends  upon  the 
changes  which  have  been  set  up  hy  the  irritation  of  the  substance  during 
its  retention.  Chronic  phthisical  symptoms  often  subside  in  a  surprising 
manner  after  the  ejection  of  the  offending  body,  and  in  such  cases,  unless 
disoi"ganization  have  proceeded  too  far,  recovery  may  be  hoped  for.  If  ab- 
scess or  gangrene  have  been  set  up  in  the  lung,  death  generally  ensues. 

Treatment. — When  we  are  satisfied  that  a  foreign  body  is  retained  in 
the  air-tubes  treatment  must  be  energetic.  Emetics  have  been  found  of 
little  value  and  may  therefore  be  dispensed  with ;  but  if  we  are  certain 
that  the  solid  substance  is  of  small  size,  the  child  should  be  at  once  turned 
head  downwards  and  shaken  in  the  hope  of  dislodging  the  imprisoned  body 
and  aiding  its  escape  from  the  tubes.  Often  violent  cough  comes  on  during 
the  operation,  and  sometimes  so  much  spasm  is  excited  in  the  glottis  by 
the  solid  body  pressing  against  it,  that  our  efforts  have  to  be  promptly 
discontinued.  This  proceeding  is  more  likely  to  be  attended  by  good  re- 
sults if  the  substance  is  small.  A  shot,  a  seed,  or  object  of  similar  size, 
would  be  able  to  pass  without  difficulty  between  the  vocal  cords,  while  a 
larger  one  might  become  impacted  in  the  glottis  and  cause  speedy  death 
by  suffocation.  Whenever,  therefore,  the  foreign  body  is  known  to  be  of 
some  size,  it  is  wiser  to  postpone  all  violent  measures,  such  as  eversion  and 
succussion,  until  an  artificial  opening  has  been  established  in  the  trachea. 
This  procedure  is  equally  important  whether  the  imprisoned  body  be  fixed 
or  be  free  to  move.  If  it  be  fixed,  the  air-tube  can  be  directly  searched  by 
a  long  forceps,  and  the  object  may  sometimes  be  seized  and  withdrawn  in 
this  manner.  If  it  be  free  to  move,  an  artificial  opening  in  the  trachea  is  a 
great  aid  to  its  escape,  as  under  these  altered  conditions  the  glottis  relaxes 
readily  and  there  is  no  risk  of  dangerovis  spasm. 

After  the  operation  the  imprisoned  body  may  be  ejected  through  the 


534  DISEASE   IN   CHILDKEN. 

wound  or  may  pass  througli  the  relaxed  glottis.  In  the  latter  case  it  is  apt 
to  be  swallowed.  If,  therefore,  it  be  not  found  after  the  signs  of  suffering 
have  subsided,  the  stools  must  be  carefully  examined. 

If  the  early  measures  for  promoting  the  escape  of  the  solid  body  do  not 
succeed,  or  if  on  account  of  the  size  of  the  substance  we  fear  to  employ  them, 
it  is  seldom  judicious  to  delay  the  operation  of  tracheotomy.  It  must  be 
remembered  that  it  is  only  in  exceptional  cases  that  the  continued  presence 
of  a  foreign  substance  in  the  air-tubes  has  been  borne  without  dangerous 
injury  to  the  lung.  As  long  as  it  remains  in  the  respiratory  passages  there 
is  constant  danger  of  suffocation  from  the  lodging  of  the  object  in  the 
larynx,  and  of  serious  disorganization  of  the  lungs  from  the  irritation  set 
up  in  the  tubes.  Therefore,  if  we  are  satisfied  that  a  solid  body  is  impris- 
oned in  the  passages,  the  fact  that  the  resulting  symptoms  are  not  urgent 
should  not  induce  us  to  postpone  the  operation.  As  ]Mr.  Barwell  has  ob- 
served, "If  a  body  be  impacted  in  the  larynx  or  trachea,  urgent  symptoms 
will  mean  merely  increased  irritability  and  spasm  of  the  glottis,  and  on  re- 
moval of  the  foreign  body  this  will  naturally  cease.  If  the  body  be  in  the 
bronchus  and  do  not  move,  urgent  symptoms  will  mean  the  estabhshment 
of  serious  disease  in  the  lung,"  and  this  may  not  disappear  when  the  for- 
eign substance  is  removed. 

The  operation  is  equally  necessary  whatever  be  the  nature  of  the 
substance  in  the  trachea.  Soft  matters,  such  as  gristle,  etc.,  wiU  not  be- 
come disintegrated  in  the  air-tubes  ;  and  small  vegetable  substances,  such 
as  seeds  and  grains  of  corn,  may  swell  up  to  a  much  larger  size  through 
absorption  of  moisture. 


JPart  7. 
DISEASES  OF  THE  HEART. 


CHAPTER  I. 

CONGENITAL   HEAET   DISEASE. 


Like  other  parts  of  the  body  the  heart  is  subject  to  malformations  from 
arrest  of  development.  These  vary  in  importance  according  to  the  period 
of  intra-uterine  life  in  which  they  occur ;  but  all,  since  they  affect  the 
centre  of  the  circulatory  system,  materially  hamper  the  distribution  of 
the  blood-current  and  therefore  interfere  with  the  due  discharge  of  all  the 
nutritive  functions  of  the  body. 

In  its  progress  from  the  simphcity  of  its  rudimentary  s-tate  to  the  com- 
plex machinery  of  the  fully  developed  organ,  the  heart  passes  through  a 
variety  of  changes.  At  first  a  mere  tube  doubled  upon  itself,  it  soon  be- 
comes divided  into  three  cavities — a  simple  auricle,  a  simple  ventricle,  and 
the  arterial  bulb.  At  this  stage  the  organ  resembles  a  horse-shoe  in 
shape,  the  ventricle  occupying  the  position  of  the  curve.  This  cavity  then 
begins  to  bulge  out  more  conspicuously  at  its  lower  part  so  as  to  suggest 
by  its  appearance  the  later  form  of  the  heart ;  and  at  the  same  time  the 
auricle  and  the  bulb  approach  more  closely  together.  Next,  the  auricle 
and  ventricle  become  each  divided  into  two  parts  by  a  septum  ;  and  the 
bulbus  arteriosus  is  also  di\dded  into  two  channels  which  are  the  future 
aorta  and  pulmonary  artery.  The  auricular  and  ventricular  septa  are 
each  at  first  incomplete,  so  that  the  cavities  severally  communicate  ;  and 
the  opening  in  the  auricular  septum — the  foramen  ovale — remains  open 
until  birth. 

Just  before  the  completion  of  intra-uterine  existence  the  course  of  the 
blood-ciuTent  is  as  follows  : — Starting  from  the  placenta,  in  which  it  has 
been  to  a  certain  extent  purified  and  recharged  with  oxygen,  the  blood 
enters  the  body  of  the  foetus  through  the  umbilical  vein  and  is  conveyed 
to  the  under  service  of  the  liver.  At  this  point  a  portion  passes  du'ectly 
into  the  inferior  vena  cava  by  the  ductus  venosus ;  the  remainder  joins  the 
blood  in  the  portal  vein  and  circulates  through  the  liver  before  it  reaches 
the  inferior  vena  cava  and  is  conveyed  with  the  first  portion  to  the  right 
auricle.  Here  it  meets  with  the  blood  returning  from  the  head  and  neck 
by  the  superior  vena  cava.     The  two  currents  do  not,  however,  mix.     That 


536  DISEASE  IN   CHILDREN. 

coming  from  the  head  passes,  as  it  would  do  in  the  adult,  through  the 
auriculo-ventricular  orifice  to  the  right  ventricle.  From  this  point  a  small 
quantity  reaches  the  lungs  through  the  pulmonary  artery  ;  but  the  larger 
portion  is  directed  through  the  ductus  arteriosus  into  the  aorta  below  the 
origin  of  the  great  vessels,  and  passes  to  the  lower  part  of  the  body  and 
the  placenta.  The  blood  reaching  the  right  auricle  by  the  inferior  vena 
cava,  instead  of  entering  the  right  ventricle,  is  directed  by  the  Eustachian 
valve  through  the  foramen  ovale  into  the  left  auricle.  Consequently, 
this  portion  of  the  blood  also  escapes  the  passage  through  the  lungs,  and 
is  distributed  by  the  left  ventricle  to  the  head  and  body  generally  through 
the  aorta. 

At  birth,  the  lungs,  which  had  been  previously  inactive,  come  into  play, 
and  blood  is  drawn  into  them  through  the  pulmonary  artery.  As  a 
necessary  consequence,  the  foramen  ovale  ^  and  ductus  arteriosus — the 
channels  by  means  of  which  the  passage  through  the  lungs  had  been 
avoided,  become  useless.  The  arterial  duct  contracts  and  ceases  to  be 
pervious  ;  while  the  foramen  ovale  also  closes  and  the  separation  of  the 
auricles  is  henceforth  complete. 

The  arrest  of  development  of  the  heart,  which  is  the  cause  of  the  con- 
genital malformation,  may  occur  at  any  of  the  stages  which  have  been 
referred  to.  The  heart  may  retain  its  nearly  primitive  form  of  a  dovible 
cavity  with  only  rudimentary  divisions  between  the  two  sides,  and  the 
aorta  and  pulmonary  artery  may  be  still  undeveloped  from  the  original 
arterial  trunk.  This  form  is  not  common,  but  examples  have  been  no- 
ticed. In  the  earliest  of  these,  placed  on  record  by  Mr.  Wilson  in  1788, 
the  infant  survived  its  birth  seven  daj's. 

If  the  arrest  take  place  at  a  later  period,  the  septa  dividing  the  cavities 
are  more  nearly  complete,  and  the  aorta  and  pulmonary  artery  are  distinct 
vessels.  This  condition  is  far  more  common  than  the  preceding.  Its 
prominent  feature,  in  addition  to  the  still  imperfect  state  of  the  partitions, 
is  a  displacement  or  even  a  transposition  of  the  great  vessels.  The  aorta 
is  displaced  to  the  right,  arising  in  part  from  the  right  ventricle ;  or  it 
springs  completely  from  that  cavity  and  the  pulmonary  artery  takes  its 
origin  from  the  left  ventricle.  When  the  aorta  is  merely  displaced  to  the 
right,  without  malposition  of  the  pulmonary  artery,  we  usually  find  some 
obstruction  to  the  passage  of  blood  from  the  right  ventricle  through  the  lat- 
ter vessel.  The  artery  is  too  small,  or  its  valves  are  incomplete,  or  the 
blood  is  prevented  from  passing  freely  into  it  by  some  constriction  of  the 
ventricle  near  the  outlet,  or  its  channel  may  be  even  entirely  obliterated. 
In  all  such  cases  the  foramen  ovale  must  remain  open  or  the  circulation 
could  no  longer  be  carried  on.  The  blood  being  unable  to  find  its  way  in 
sufficient  quantity  to  the  left  side  of  the  heart  through  the  lungs,  con- 
tinues to  follow  its  original  course  through  the  oj^ening  in  the  auricular 
septum,  and  the  foramen  ovale  is  prevented  from  closing.  If,  however,  in 
such  a  case  the  aorta  arise  sufficiently  to  the*  right  to  allow  of  the  escape 
of  blood  through  it  from  the  right  ventricle,  the  foramen  ovale  and  ductu.s 
arteriosus  may  cease  to  be  pervious. 

Constriction  of  the  pulmonary  artery  with  deficiency  in  the  septum  of 
the  ventricles,  so  that  the  aorta  communicates  with  the  right  ventricular 
cavity,  is  the  commonest  form  of  congenital  malformation  of  the  heart. 
Whether  in  such  a  case  the  foramen  ovale  and  ductus  arteriosus  are  closed 

'  Under  normal  conditions  the  foramen  ovale  should  be  closed  by  the  end  of  the 
first  week,  and  the  ductus  arteriosus  by  the  end  of  the  third  month  after  birth. 


COISTGENITAL   HEART  DISEASE — MOEBID   ANATOMY.  537 

or  not  depends,  as  has  been  said,  upon  the  freedom  with  which  the  blood 
can  escape  from  the  right  side  of  the  heart  through  the  displaced  aorta. 
If  the  right  ventricle  is  not  unduly  distended,  and  the  pulmonary  artery- 
allows  enough  blood  to  get  away,  both  these  channels  may  become  closed. 
In  the  other  case,  where  the  aorta  and  pulmonary  artery  are  transposed, 
the  septum  of  the  ventricles  is  usually  imperfect,  and  the  foramen  ovale 
and  ductus  arteriosus  still  remain  open. 

Sometimes  the  descending  aorta  is  found  to  arise  fi'om  the  pulmonary 
artery,  being  apparently  a  continuation  of  the  ductus  arteriosus.  In  tlais 
case  a  small  ascending  aorta  springs  from  the  left  ventricle  to  supply  the 
head  and  neck  by  the  usual  vessels.  The  j)u.lmonary  artery  communicates 
through  an  opening  in  the  ventricular  septum  with  the  left  ventricle.  The 
foramen  ovale  is  usually  closed. 

In  contradistinction  to  the  class  of  cases  where  the  foetal  openings  re- 
main pervious  after  birth  is  another  class  in  which  these  orifices  close  too 
early,  before  uterine  life  has  reached  its  term.  If  the  foramen  ovale  is 
obliterated  prematurely,  the  whole  quantity  of  blood  has  to  pass  through 
the  pulmonary  artery  and  ductus  arteriosus.  Consequently,  the  right  side 
of  the  heart  is  enormously  hypertrophied  while  the  left  side  is  smaller 
than  natural.  In  cases  where  the  ductus  arteriosus  has  undergone  early 
obliteration,  the  aorta  usually  springs  from  the  right  ventricle,  and  this 
vessel  commonly  gives  branches  to  the  lungs,  the  pulmonary  artery  being 
very  small  and  rudimentary. 

Besides  the  varieties  which  have  been  mentioned,  the  congenital  disease 
may  also  consist  in  defects  in  the  valves,  or  in  narrowing  of  the  orifices  of 
the  large  vessels  which  spring  from  the  heart.  Sometimes,  as  in  the  pre- 
ceding cases,  the  defect  may  arise  from  malformation,  as  when  the  num- 
ber of  the  valves  is  deficient  or  otherwise  abnormal ;  but  it  may  alsa  be 
due  to  intra-uterine  endocarditis.  Inflammation,  when  it  attacks  the  foetal 
heart,  almost  invariably  affects  the  right  side,  which  at  this  period  of  life 
is  more  active  than  the  left.  The  tricuspid  valve  may  be  beaded,  or  the 
pulmonary  semi-lunar  valves  may  be  more  or  less  adherent.  In  many 
cases  the  three  pulmonary  valves  are  found  united  into  a  funnel-shaped 
dome  with  a  small  orifice  at  the  apex,  through  which  the  blood  is  pro- 
pelled with  difficulty.  A  similar  atresia  of  the  aortic  orifice  is  much  less 
frequently  met  with.  When  the  latter  malformation  exists,  the  arteries  of 
the  head  and  upper  limbs  are  probably  filled  thi'ough  the  pulmonary  artery 
by  the  ductus  arteriosus. 

It  is  possible  that  these  inflammatory  lesions  may  be  occasionally  ex- 
cited, as  Dr.  Yon  Hoffman  suggests,  by  extravasation  into  the  j)lacenta, 
from  which  hsemorrhagic  foci,  j)athological  products,  may  be  introduced 
through  villous  absorption  into  the  foetal  circulation. 

Morhid  Anatomy. — In  addition  to  the  malformations  which  have  been 
described,  the  heart  is  always  found  to  be  greatly  enlarged,  especially  on 
the  right  side.  Moreover,  morbid  conditions  are  usually  seen  in  other 
organs.  There  is  often  more  or  less  atelectasis  of  the  lungs,  and  the  ex- 
panded portions  have  a  dark,  congested  appearance.  The  liver  and  spleen 
are  not  uufrequently  swollen  and  congested  ;  and  effusions  may  be  found 
in  the  pleura  and  peritoneum.  Also,  morbid  conditions  of  the  brain  are 
common.  There  may  be  congestion  or  inflammation  or  effusion  ;  or  an 
abscess  may  be  formed  in  its  substance. 

The  congenital  imperfections  of  the  heart  may  be  complicated  by  in- 
flammation in  or  around  the  organ,  for  the  original  malformation,  far 
from  guarding  the  patient  from  subsequent  inflammation,  appears  rather 


538  DISEASE  IN   CHILDEElSr. 

to  prepare  the  way  for  it.  We  may  therefore  find  the  anatomical  charac- 
ters of  endocarditis  or  inflammation  of  the  pericardium. 

Symptoms. — In  cases  of  congenital  heart  disease  the  most  striking 
symptom  is  the  purplish  or  Hvid  tint  of  the  skin  which,  if  the  child  sur- 
vive its  birth  many  months,  rarely  fails  to  be  developed.  Indeed,  from 
this  peculiarity  of  colour  such  cases  are  often  spoken  of  as  cases  of  cyano- 
sis or  "  morbus  coeruleus."  The  depth  of  the  purple  tint  varies  greatly  in 
different  subjects.  In  some  it  merely  gives  a  dusky  or  swarthy  hue  to  the 
skin.  In  others  the  discolouration  may  reach  a  deep  pui-ple  or  even  almost 
a  black  colour.  It  is  distinguishable  in  all  parts  of  the  body  ;  but  is  most 
noticeable  in  the  cheeks,  hps,  and  eyelids,  and  also  in  the  ends  of  the 
fingers  and  toes.  Even  in  the  same  subject  the  symptom  is  hable  to 
variation.  While  the  child  is  completely  at  rest  the  tint  most  nearly  ap- 
proaches the  normal  colouring ;  but  movement,  especially  fretfulness  or 
anger,  makes  the  skin  darker  at  once.  The  cause  of  the  cyanotic  tint  has 
been  the  subject  of  discussion.  By  Morgagni  it  was  attributed  to  intense 
general  congestion,  and  by  Hunter  to  great  contamination  of  the  arterial 
current  with  unoxygenized  blood.  The  latter  view  has  been  shown  to  be 
untenable.  Cyanosis  may  exist  without  any  admixture  of  venous  and  arte- 
rial blood ;  and  in  many  cases  where  such  admixture  occurs  the  depth  of 
tint  is  not  in  proportion  to  the  amount  of  venous  blood  which  is  poured 
into  the  aorta.  Dr.  Peacock  gives  his  support  to  the  theory  of  Morgagni, 
and  attributes  the  discolouration  to  stasis  of  blood  in  capillaries  dilated  by 
long-standing  congestion,  aided  by  imperfect  aeration  of  the  whole  mass 
of  the  circulating  fluid. 

The  cyanotic  tint  is  not  always  an  early  symptom.  We  often  find  that 
the  child  at  birth  presented  no  peculiarity  of  colour,  and  that  it  was  only 
after  an  interval  of  weeks  or  months  that  anything  was  noticed  to  excite 
suspicions  of  disease.  In  less  common  cases  the  tint  of  the  skin  is  normal 
throughout. 

In  addition  to  the  blueness  of  the  ends  of  the  fingers  and  toes,  these 
parts  are  usually  clubbed  from  systemic  venous  congestion,  and  the  naUs 
are  incurvated.  The  shape  of  the  chest  is  often  pecuhar.  It  is  sometimes 
called  "  pigeon-breasted,"  but  the  prominence  of  the  sternum  is  only  no- 
ticeable at  the  lower  part  from  flattening  in  each  infra-mammary  region. 
At  the  upper  part  the  chest  is  abnormally  prominent  and  roimded.  The 
coldness  of  the  hands  and  feet  is  another  striking  peculiarity  in  a  cyanotic 
child.  Indeed,  the  external  temperatm-e  of  the  body  may  be  several  de- 
grees below  the  normal  level ;  but  if  the  thermometer  be  placed  in  the  rec- 
tum the  internal  temperature  wUl  be  found  httle  lower  than  natm-al.  It 
is,  however,  subject  to  variations,  being  sometimes  for  several  days  below 
the  normal  level  (97°-98°) ;  at  other  times  more  nearly  natural.  In  these 
patients,  as  in  healthy  children,  the  ordinary  heat  of  the  body  is  liable  to 
be  disturbed  by  teething  and  other  sources  of  irritation  ;  and  is  sometimes 
found  to  run  up  to  102°  or  even  higher  from  this  cause. 

Dyspnoea  and  palpitation  of  the  heart  are  common  symptoms.  In  the 
case  of  an  infant  the  mother  often  remarks  upon  the  beating  of  her  child's 
heart  when  the  patient  is  washed  or  otherwise  disturbed  :  and  older  chil- 
dren may  complain  spontaneously  of  the  throbbing  when  they  attempt  to 
run.  At  these  times  there  is  usually  shortness  of  breath,  and  cough  may 
be  present.  In  some  cases  when  the  cyanosis  is  extreme,  the  cough  may 
be  accompanied  by  the  expectoration  of  blood.  The  pulse  is  often  irreg- 
ular and  intermittent,  but  its  strength  is  fair. 

Sometimes   dropsical  symptoms  come  on.     There  may  be  oedema  of 


CO]SrGE]SriTAL   HEART  DISEASE — SYMPTOMS.  539 

the  legs,  or  ascites  ;  but  serous  effusions  are  less  common  tlian  might  be 
supposed,  for,  as  Dr.  Chevers  has  pointed  out,  the  venous  system  seems  to 
adapt  itself  to  the  overloading.  The  right  auricle,  cava,  and  systemic  veins 
are  often  of  unusual  capacity  from  the  first ;  and  the  veins  of  the  liver  are 
capable  of  containing  a  vast  quantity  of  delayed  blood.  The  superficial 
veins  of  the  chest  or  limbs  are  rarely  more  visible  than  natural,  but  the 
skin  is  habitually  dry  and  may  be  harsh.  The  liver  and  spleen  can  often 
be  felt  to  be  enlarged  ;  and  on  account  of  the  congestion  of  the  kidneys 
the  luine  is  habitually  scanty  and  high  coloured.  On  account,  too,  of  the 
congestion  of  the  ahmentary  canal,  the  tongue  is  generally  foul,  the  breath 
offensive,  and  the  digestion  feeble.  The  appetite  is  poor  or  capricious  ; 
and  the  bowels  costive  or  irregular,  with  clay-coloured  pasty  stools.  The 
gums  are  often  dark-coloured  and  spongy-looking,  and  may  be  ulcerated 
at  their  edges.     Sometimes  they  bleed. 

Cyanotic  children  are  generally  irritable  and  easily  disturbed.  Conse- 
quently at  a  first  examination  it  is  often  impossible  to  come  to  a  satisfac- 
tory conclusion  even  as  to  the  physical  signs  present  in  the  case.  These 
are  liable  to  vary  according  to  the  character  of  the  congenital  lesion,  and 
may  possibly  be  absent  altogether  ;  for  if  the  malformation  consist  in  a 
mere  transposition  of  the  aorta  and  pulmonary  artery,  without  narrowing 
of  the  channels  or  persistence  of  the  foetal  openings,  no  murmur  will  be 
beard,  and  careful  examination  will  detect  no  sign  of  cardiac  enlargement. 
The  most  common  malformation,  as  has  been  said,  is  that  in  which  the 
pulmonary  artery  is  greatly  constricted,  and  the  septum  between  the  ven- 
tricles is  deficient,  so  that  the  aorta  appears  to  arise  in  part  from  the  right 
ventricle.  In  such  a  case  there  is  great  hypertrophy  of  the  right  ventricle  ; 
we  find  a  very  strong  pulsation  all  over  the  prsecordial  region,  and  a 
forcible  impulse  between  the  left  nipple  and  the  ensiform  cartilage.  The 
impact  may  be  accompanied  by  a  systolic  thrill.  On  listening  to  the 
chest  we  hear  a  loud  systolic  murmur  in  the  course  of  the  pulmonary 
artery.  In  the  case  of  a  boy  who  died  at  the  age  of  nearly  six  years  in  the 
East  London  Children's  Hospital  with  this  condition,  the  apex  beat  of  the 
heart  was  in  the  fifth  interspace  in  the  nipple  line.  The  impulse  was  felt 
very  strongly  over  the  whole  praecordial  region,  in  the  epigastrium,  and 
even  to  the  right  of  the  lower  part  of  the  sternum.  The  arteries  in  the  neck 
also  pulsated  strongly.  A  loud  systolic  murmur  was  heard  all  over  the  front 
and  back  of  the  thorax.  It  was  rather  louder  at  the  base  of  the  heart  than 
at  the  ajDex,  and  became  much  fainter  towards  the  armpits.  The  point 
of  greatest  intensity  was  over  the  site  of  the  pulmonary  valves.  In  this 
child  there  was  no  discolouration  of  the  skin. 

Even  a  jDatent  foramen  ovale  without  constriction  of  orifices  or  other 
abnormal  condition  will  give  rise  to  a  murmur.  In  a  case  published  by 
Dr.  Balthazar  Foster — in  a  little  girl  of  two  years  old — a  faint  murmur 
was  heard  with  the  latter  part  of  the  first  sound  at  the  level  of  the  lower 
edge  of  the  third  rib  at  its  junction  with  the  sternum.  It  did  not,  however, 
extend  over  a  wide  area,  and  was  audible  neither  at  the  base  of  the  heart 
nor  the  aj^ex. 

Infants  who  suffer  from  congenital  malformation  of  the  heart  are 
usually  thin.  If,  however,  the  patient  survive  the  period  of  infancy,  he 
may  not  be  wasted  and-  may  even  have  a  sturdy  appearance.  He  is 
usually  lethargic  and  dull  of  intellect ;  and  is  cautious  in  his  movements, 
as  experience  has  taught  him  that  exertion  is  apt  to  be  followed  by  palpi- 
tation and  dyspnoea.  In  most  cases  where  serious  malformation  of  the 
heart  exists  the  patient  is  subject  to  attacks  of  syncope,  and  often  symp- 


540  DISEASE  IN   CHILDKElSr. 

toms  occur  referable  to  disorder  of  the  nervous  system.  In  the  case  re- 
ferred to  above,  the  patient  died  of  cerebritis.  Another  cyanotic  child 
under  my  care  in  the  East  London  Children's  Hospital — a  httle  girl  nearly 
two  years  old — suffered,  while  she  remained  under  observation,  from  general 
loss  of  power,  with  ptosis  of  the  right  eyelid  and  contraction  with  rigidity 
of  the  muscles  of  the  left  forearm.  The  child  had  all  the  signs  of  carious 
disease  of  the  right  petrous  bone.  Disease  of  this  part  of  the  skull  seems 
to  be  a  not  uncommon  lesion  in  children  who  suffer  from  congenital  mal- 
formation of  the  heart.  Dr.  Lawrence  Humphry  has  kindly  communicated 
to  me  the  notes  of  a  case  which  occurred  during  his  period  of  office  as 
Kesident  Physician  in  the  Victoria  Park  Hospital.  The  patient — a  cyanotic 
boy  between  five  and  six  years  old — had  suffered  from  long-continued 
otorrhoea.  A  fortnight  before  his  death  the  discharge  ceased.  The  child 
then  began  to  complain  of  headache,  which  became  veiy  severe.  This 
symptom  was  soon  followed  by  attacks  of  -violent  con"\nilsions,  without  loss 
of  consciousness  in  the  inteiwals,  and  the  boj^  died  in  a  few  days.  After 
death,  in  addition  to  the  ordinary  form  of  congenital  malformation  (stenosis 
of  the  pulmonary  artery,  deficiency  in  the  ventricular  septum,  and  origin  of 
the  aorta  from  both  ventricles)  an  abscess  was  found  in  the  middle  lobe 
of  the  left  cerebral  hemisj^here,  and  the  petrous  bone  on  that  side  was  dis- 
eased. 

Convulsions  are  very  common,  especially  in  infants  ;  and  startings  and 
twitchings  during  sleep  are  seldom  absent  whatever  be  the  age  of  the  pa- 
tient. Another  curious  symptom  is  great  hea\4ness  and  somnolence.  In 
many  cyanotic  children  attacks  of  uncontrollable  sleej^iness  form  a  promi- 
nent feature  in  the  case.  These  attacks  are  apt  to  come  on  after  a  meal  The 
child  shows  symptoms  of  great  di'owsiness  ;  the  face  becomes  purple,  and 
the  breathing  slow  and  heavy.  In  extreme  cases  the  sleep  becomes  so 
profound  that  it  resembles  coma  and  the  child  cannot  be  roused.  After 
some  hom's,  however,  the  patient  revives,  his  heaviness  passes  off,  and  he 
is  restored  to  his  normal  condition. 

The  duration  of  Hfe  is  very  variable.  It  is  dependent  chiefly  upon  the 
degree  of  obstruction  to  the  cii'culation.  Nearly  one-half  of  the  cases  die 
before  they  have  completed  the  first  year,  and  two-thirds  before  they  are 
two  years  old.  Death  often  occurs  in  a  convulsive  fit ;  and  infants  usually 
die  in  or  directly  after  such  a  seiziu-e.  Moreover,  attacks  of  syncope  are 
common,  and  the  failui*e  of  the  heart's  action  is  sometimes  not  recovered 
from.  In  some  cases  the  patient  falls  a  -victim  to  pneumonia  or  other  in- 
tercurrent disease  ;  indeed,  on  account  of  the  impaired  state  of  nutrition 
usually  prevaihng,  the  resisting  power  of  the  child  is  feeble,  and  derange- 
ments prove  fatal  which  a  stronger  subject  would  have  httle  difficulty  in 
overcoming.  Many  of  these  children  become  tubercular  or  jDhthisical,  and, 
as  has  been  said,  in  not  a  few  cases  death  is  preceded  by  symptoms  point- 
ing to  cerebral  mischief. 

Diagnosis. — A  child,  cyanotic  from  malformation  of  the  heart,  presents 
a  very  characteristic  appearance.  His  dusk}'  tint,  his  purple  lips  and  eye- 
lids, his  livid  and  clubbed  finger-tips — these  symptoms,  together  with  the 
physical  signs  and  the  history  of  the  patient,  can  leave  httle  doubt  as  to  the 
existence  of  a  congenital  lesion  of  the  heart.  If,  however,  cyanosis  is  ab- 
sent, the  nature  of  the  case  is  less  immediately  recognisable  ;  iDut  by  a  care- 
ful review  of  the  physical  signs  we  can  usually  arrive  at  a  correct  conclu- 
sion. If  we  are  able  to  localize  the  murmur  at  the  pulmonary  orifice,  and 
can  discover  signs  of  hypertrophy  of  the  right  ventricle  (increase  of  the 
heaa-t's  dulness  to  the  right  with  pulsation  in  the  epigastrium),  these  signs 


CONGElSriTAL   HEAET   DISEASE — DIAGE-QSIS.  541 

are  almost  pathognomonic  of  congenital  disease,  lor  endocarditis  affecting 
the  right  side  of  the  heart  is  rare  after  birth.  Sometimes,  on  account  of 
the  small  size  of  the  chest  in  young  subjects,  it  is  impossible,  especially  in 
an  infant,  to  discover  the  point  of  greatest  intensity  of  the  murmur.  In 
such  a  case,  signs  of  hypertrophy  of  the  right  heart  are  doubly  important ; 
and  if  we  notice  clubbing  of  the  finger-ends,  and  find  that  after  movement 
the  child's  face  becomes  livid  or  his  lips  blue,  the  existence  of  congenital 
heart  disease,  in  the  absence  of  any  affection  of  the  lungs,  may  be  safely  as- 
serted. According  to  some  observers,  attacks  of  dyspnoea  alone,  occurring 
from  trifling  causes,  are  very  suspicious  of  this  form  of  lesion.  Louis  was 
of  opinion  that  "  suffocative  attacks  brought  on  by  the  slightest  cause, 
often  jDeriodic,  always  very  frequent,  and  accompanied  or  followed  by  syn- 
cope, and  with  or  without  blue  discolouration  of  the  body,  generally"  formed 
suflScient  grounds  for  the  diagnosis  of  an  abnormal  communication  between 
the  right  and  left  cavities  of  the  heart.  Again,  the  occurrence  of  tubercu- 
losis in  a  child  the  subject  of  old-standing  heart  disease,  although  not  con- 
clusive evidence,  points  very  decidedly  to  a  congenital  origin  for  the  car- 
diac mischief. 

Even  in  cases  where  all  necessary  symptoms  are  present,  and  the  con- 
genital origin  of  the  heart-lesion  is  unmistakable,  the  exact  variety  of  mal- 
formation must  often  remain  a  mystery.  The  difficulties  in  ascertaining  the 
form  in  which  the  arrest  of  development  has  occurred  are  very  great.  In 
the  case  of  a  fully  developed  heart  we  are  dealing  with  an  organ  the 
structure  of  which  is  known.  We  are  acquainted  with  the  number  and 
situation  of  its  openings,  the  number  and  mechanism  of  the  valves  which 
close  them,  and  the  direction  normally  taken  by  the  current  of  blood.  In 
such  a  heart  any  morbid  alteration  of  the  physical  signs  has  a  definite 
meaning  ;  and  in  ordinary  cases  there  is  little  uncertainty  as  to  the  cause 
which  has  given  rise  to  it.  In  the  case  of  a  heart  the  seat  of  a  congenital 
malformation,  the  conditions  are  very  different.  The  number  of  openings 
is  undetermined  ;  their  position  is  doubtful,  and  even  the  direction  in 
which  the  blood  is  flowing  can  only  be  conjectured.  In  such  cases,  there- 
foi'e,  an  exact  diagnosis  is  often  impossible.  Still,  there  are  certain  general 
rules  which  should  not  be  forgotten.  Thus,  some  forms  of  malformation 
jorove  very  quickly  fatal.  An  infant  whose  heart  remains  in  a  primitive 
state,  consisting  merely  of  two  cavities,  will  probably  be  dead  within  a 
month.  Therefore  at  a  more  advanced  age  this  variety  may  be  excluded. 
Another  form  of  congenital  disease  which  usually  has  an  early  termination 
is  transposition  of  the  aorta  and  pulmonary  artery.  Children  in  whom 
this  form  of  malformation  occurs  rarely  live  longer  than  two  or  at  the  most 
three  years.  One  little  boy  under  my  care  with  this  form  of  lesion  sur- 
vived to  the  age  of  eighteen  months  ;  but  the  majority  of  the  recorded 
examples  have  died  within  the  first  twelve  months.  So,  also,  the  variety 
which  consists  in  the  origin  of  the  aorta  from  the  pulmonary  artery  is  not 
likely  to  be  present  in  a  child  who  has  survived  the  first  year. 

In  children  who  have  reached  the  age  of  three  years  the  above  condi- 
tions may  be  excluded  with  a  high  degree  of  probability.  At  this  age  we 
should  search  for  signs  indicative  of  atresia  of  the  pulmonary  artery.  If 
we  can  localize  the  murmur  over  the  j)ulmonary  valves,  and  can  ascertain 
the  existence  of  hypertrophy  of  the  right  side  of  the  heart,  we  may  safely 
infer  the  presence  of  contraction  of  the  orifice  of  the  pulmonary  artery. 
In  such  a  case  there  is  probably  also  deficiency  of  the  ventricular  septum, 
with  a  communication  between  the  aorta  and  the  right  ventricle,  and  per- 
haps patency  of  the  arterial  duct.      This,   it  may  be  repeated,   is    the 


542  DISEASE   IIS-   CHILDEEN". 

commonest  form  of  congenital  malformation.  Still,  other  morbid  condi- 
tions of  "u-bich.  Ave  know  notMng  may  also  be  present.  Patency  of  the 
foramen  ovale  is  seldom  the  only  abnormahty,  but,  if  in  a  child  of  three 
years  old  or  TijDwards  we  find  the  symptoms  of  congenital  heart  disease 
without  cardiac  mui-mur,  or  with  a  very  faint  bi-uit  hmited  strictly  to  the 
level  of  the  third  interspace  towards  the  middle  line,  and  without  signs  of 
hypertrojDhy  of  the  right  ventricle,  this  condition  may  be  suspected  In 
no  case,  probably,  can  a  positive  diagnosis  be  arrived  at ;  at  least,  we  can 
never  say  that  the  condition  diagnosticated  is  the  only  cai'diac  lesion 
present. 

Prognosis. — The  prospects  of  a  child,  the  subject  of  congenital  mal- 
formation of  the  heart,  are  necessarily  veiy  luifavourable.  On  account  of 
the  difficulties  under  which  his  circulation  is  carried  on,  and  the  persistent 
congestion  of  his  whole  venous  system,  the  child's  nutrition  is  faulty  and 
his  vitality  low.  He  has  therefore  httle  power  to  throw  off  even  trifling 
derangements,  and  is  pecuharly  sensitive  to  distui'bing  influences.  In  ad- 
dition, then,  to  the  dangers  dii'ectly  attendant  ujDon  his  congenital  defect, 
he  is  exjDosed  to  constant  risk  fi'om  the  serious  consecjuences,  in  his  en- 
feebled state,  of  the  ordinary  ailments  of  childhood.  Every  change  in  the 
gTowth  and  develoj)ment  of  the  infant  is  a  new  period  of  trial.  The  first 
establishment  of  the  respiratoiy  function  at  birth,  the  occurrence  of  denti- 
tion, the  time  of  weaning,  and  all  the  innumerable  causes  of  disturbance 
to  which  infant  hfe  is  liable,  are  distinct  soui'ces  of  peril.  To  one  or 
another  of  such  dangers  a  large  proportion  of  these  patients  succumb  ; 
and,  as  has  ah-eady  been  stated,  hardly  one-thii-d  of  the  whole  number  of 
cases  survives  to  the  age  of  two  years. 

On  account  of  the  difficulty  of  ascertaining  the  exact  variety  and  extent 
of  the  cardiac  defect,  the  prognosis  dra-ing  the  first  few  months  of  hfe  is 
especially  serious.  Later,  as  the  child  grows  and  arrives  at  a  period  when 
the  more  fatal  forms  of  malformation  may  be  excluded,  his  prospects  im- 
prove ;  but  they  can  rarely  be  said  to  be  othei^se  than  unfavourable,  for 
a  comparatively  small  proportion  of  these  patients  hve  to  attain  adult  years. 

Of  special  symptoms,  some  should  be  regarded  T\-ith  anxiety.  Frecjuent 
attacks  of  syncope  are  dangerous  ;  great  drowsiness  is  of  unfavourable 
omen  ;  and  convulsions  or  other  sign  of  cerebral  irritation  have  a  very  sin- 
ister meaning.  According  to  Dr.  Chevers,  failui'e  of  the  renal  secretion,  or 
the  occurrence  of  albuminuria,  as  indicating  the  probable  beginning  of 
sti'uctui'al  changes  in  organs  which  have  always  been  hampered  in  the  dis- 
charge of  their  functions,  is  to  be  viewed  with  much  apprehension. 

Treatment. — The  treatment  of  these  cases  consists  in  the  adoption  of  wise 
rules  for  the  diet  and  general  management  of  the  patient,  and  in  early  atten- 
tion to  any  intercurrent  disorder  by  which  he  may  be  attacked.  On  account 
of  the  general  sensitiveness  to  chills,  and  the  tendency  to  lowering  of  the 
temperature,  the  child  must  be  warmly  dressed  with  a  flannel  band  to  his 
belly,  and  should  be  clothed  in  some  wooUen  material  fi'om  head  to  foot. 
His  diet  should  be  carefully  an-anged  so  as  to  avoid  excess  of  fermentable 
matters,  such  as  starches  and  sweets  ;  and  he  should  be  taken  out  of  doors, 
whenever  the  weather  is  not  too  unfavourable,  in  his  nurse's  arms  or  a 
suitable  caiiiage.  If  a  perambulator  be  used,  a  hot  bottle  to  the  child's 
feet  is  a  necessity  unless  the  weather  be  warm.  The  patient's  bowels  should 
be  kept  regnxlar,  and  an  occasional  mercui'ial  purge  is  useful  to  afford  some 
relief  to  his  congested  hver.  If  palpitations  are  violent,  small  doses  of  the 
infusion  of  digitalis  may  be  given  ;  and  Dr.  Peacock  speaks  highly  of  the 
beneficial  effects  of  Dover's  j)owder.     It  is  important  to  excite  the  regular 


CONGENITAL   HEAET  DISEASE — TREATMENT.  543 

action  of  the  skin,  which  in  these  patients  is  habitually  dry.  Tepid  baths 
should  be  given  twice  a  day,  and  should  be  always  followed  by  careful 
frictions  over  the  whole  body  with  the  hand.  Small  quantities  of  alcohol 
are  also  of  service,  and  may  be  given  in  the  form  of  brandy  or  the  St. 
Raphael  tannin  wine.  The  attacks  of  dyspnoea  are  best  treated  by  stimu- 
lants and  small  doses  of  digitahs  and  ammonia. 

Any  catarrh,  whether  of  the  lungs  or  bowels,  must  be  attended  to  with- 
out delay  ;  and  if  albuminuria  be  detected  in  the  urine,  or  the  renal  secre- 
tion become  scanty,  gentle  aperients  and  di-oretics  should  be  at  once  re- 
sorted to.  In  cases  of  extreme  discolouration,  the  peroxide  of  hydi'Ogen 
has  been  recommended  ;  and  Dr.  Balthazar  Foster  states  that  given  three 
times  a  day  in  eight-minim  doses  the  beneficial  effects  of  the  remedy  are 
very  decided. 


CHAPTER  IT. 

CHRONIC  VALVULAR  DISEASE  OF  THE  HEART.  ^ 

Cheonic  disease  of  the  heart  is  very  common  in  childhood  ;  and  there  are 
few  forms  of  valvular  lesion  found  in  the  adult  which  may  not  be  also  met 
with  in  the  young  subject.  The  signs  and  symptoms  to  which  such  faulty 
conditions  give  rise  are  much  the  same  at  all  ages.  A  child,  like  an  adidt, 
may  have  valvular  disease  without  himself  being  conscious  of  discomfort  or 
betraying  to  others  any  sign  of  inconvenience  ;  or  he  may  suffer  from 
breathlessness,  palpitation,  general  oedema,  and  aU  the  other  symptoms 
which  are  liable  to  arise  in  an  older  person  similarly  affected.  The  physi- 
cal signs  of  valvular  lesion,  and  of  consequent  alteration  in  size  of  the  organ, 
also  resemble  very  closely  those  met  with  in  adult  life.  It  is  not,  therefore, 
necessary  to  enter  into  these  subjects  at  great  length.  It  will  be  sufficient 
to  point  out  any  pecuhai'ities  of  feature  conferred  upon  the  cardiac  disease 
in  the  child  by  the  youthful  age  of  the  patient. 

Causation. — Amongst  the  causes  of  valvular  defect  of  the  heart,  rheuma- 
tism takes  by  far  the  most  important  place.  To  this  disease,  indeed,  most 
of  the  cases  of  heart  disease  occurring  in  early  hfe  are  to  be  attributed. 
The  manifestations  of  rheumatism  in  the  child,  as  is  stated  elsewhere,  are 
often  very  trifling ;  and  in  infancy,  on  account  of  the  difficulty  of  referring^ 
signs  of  distress  to  their  true  source,  the  disease  no  doubt  often  escapes 
detection  altogether.  Next  to  rheumatism,  scarlatina  is  perhaps  the  most 
common  cause  of  endocardial  inflammation.  This  disease  is  often  followed 
by  joint  pains  and  other  symjDtoms  indistinguishable  from  rheumatism  ;  and 
chronic  valvular  disease  of  the  heart  appears  in  not  a  few  cases  to  owe  its 
origin  to  this  exanthem.  According  to  Bouillaud,  measles  is  also  an  occa- 
sional precursor  of  endocarditis  ;  and  Dr.  Samson  has  recorded  a  case  in 
which  both  pericarditis  and  endocarditis  occun-ed  a  fortnight  after  con- 
valescence from  measles  had  begun.  This  fever,  however,  is  no  doubt  a 
much  less  common  cause  of  the  valvular  disease  than  the  other  maladies 
which  have  been  mentioned.  In  certain  cases,  chorea  appears  to  be  a  start- 
ing point  for  valvular  mischief.  Sometimes,  without  any  evidence  of  rheu- 
matism, we  find  a  murmur  become  developed  in  the  course  of  the  choreic 
attack  ;  and  it  may  happen  that  the  morbid  sound  continues  after  the  ces- 
sation of  the  nervous  derangement,  and  is  accompanied  after  a  time  by 
displacement  of  the  heart's  apex  and  other  signs  of  hypertrophy.  Still,  in 
these  and  other  cases  where  no  history  of  rheumatism  is  to  be  obtained,  it 
is  possible  that  the  endocardial  lesion  may  still  have  a  rheumatic  origin. 
The  tendency  of  this  disease  is  to  attack  the  fibrous  tissues  of  the  body 
generally  ;  but  all  need  not  suffer  at  the  same  time.  The  selection,  even,  of 
the  joints  to  be  affected  by  the  disease  is  apj)arently  capricious.    Some  are 


'  Acute  peri-  and  endo-carditis  and  their  consequences  are  considered  in  tlie  cliapter 
on  acute  rheumatism. 


CHEONIC   VALVULAR  DISEASE   OF   THE   HEART.  545 

attacked  while  others  are  passed  over.  It  is  surely,  therefore,  not  unreason- 
able to  suppose  that  the  fibrous  tissues  of  the  heart  may  be  implicated 
while  those  of  the  joints  are  left  unharmed.  In  addition  to  the  preceding, 
syphilis  may  be  an  occasional  cause  of  the  heart  lesion,  for  valvular  imper- 
fection is  sometimes  found  in  very  young  infants,  the  subjects  of  inherited 
syphilis. 

Atheromatous  degenerations,  which  are  so  common  a  cause  of  valvular 
lesion  in  the  adult,  rarely  occur  in  early  life.  It  once,  however,  happened 
to  me  to  meet  with  a  small  calcareous  mass  on  one  of  the  aortic  valves  in 
a  little  girl  three  years  old.  The  mass  had  given  rise  during  life  to_  a 
systolic  murmur  which  was  most  intense  at  the  base  of  the  heart,  but 
could  be  heard  distinctly  at  all  parts  of  the  chest.  This  child  had  never 
had  rheumatism,  as  far  as  could  be  discovered,  but  had  suffered  from 
measles  nearly  two  years  previously. 

Eickets  has  been  said  to  be  a  cause  of  hypertrophy  of  the  heart ;  but  X 
cannot  say  that  I  have  ever  myself  met  with  a  case  of  cardiac  enlargement 
which  I  was  able  to  attribute  to  the  chest  distortion  produced  by  this  dis- 
ease. When  the  framework  of  the  thorax  is  much  deformed,  the  heart  is, 
no  doubt,  forced  more  forwards  towards  the  wall  of  the  chest,  and  a  larger 
area  of  impulse  is  consequently  percejotible.  It  is  common  in  such  cases 
to  be  able  to  feel  the  contractions  of  the  right  ventricle  in  the  epigastrium  ; 
but  this  sign  alone  is  insufficient  proof  of  enlargement  of  the  right  side  of 
the  heart  in  the  absence  of  extension  of  dulness  to  the  right  of  the  sternum, 
and  other  necessary  signs  of  that  condition. 

In  some  cases  valvular  lesions  are  probably  congenital  in  their  origin, 
arising  from  endocarditis  occurring  during  intra-uterine  life.  In  most  of 
these  cases  the  valves  on  the  right  side  of  the  heart  only  are  attacked. 
Chronic  valvular  disease,  according  to  some  authors,  is  more  common  in 
boys  than  in  girls  ;  but  my  own  experience  would  point  to  a  directly  op- 
posite conclusion. 

Morbid  Anatomy. — In  most  cases  of  chronic  valvular  disease  in  the 
young  subject  the  lesion  consists  in  a  beading  or  puckering  of  valves  or 
other  cause  of  insufficiency,  or  in  a  narrowing  of  the  valvular  opening. 
The  valve  most  commonly  affected  is  the  mitral ;  the  next,  that  closing  the 
aorta.  Beading  of  the  tricuspid  valve  is  rarely  seen.  This  lesion,  how- 
ever, occurred  in  a  case  under  my  care  in  the  East  London  Children's 
Hospital.  A  girl  aged  thirteen  was  admitted,  suffering  from  general  venous 
congestion,  cyanosis,  and  anasarca.  The  child's  fingers  were  clubbed,  and 
her  breathing  was  hurried  with  some  degree  of  orthopnoea.  The  patient 
was  said  never  to  have  had  rheumatism,  but  had  suffered  from  measles  and 
scarlatina,  and  seven  years  previously  had  had  an  attack  of  chorea,  from 
which  all  her  trouble  was  dated.  On  examination  there  was  evidence  of 
great  hypertrophy  of  the  left  ventricle,  and  a  strong  pre-systolic  thrill  and 
loud  pre-systolic  murmur  were  discovered  at  the  apex.  There  was  also  a 
short  diastolic  thrill  at  the  base  to  the  left  of  the  sternum,  and  a  diastolic 
murmur  was  heard  at  this  spot.  There  were,  in  addition,  signs  of  double 
hydrothorax.  On  examination  of  the  body  after  death,  the  heart  was 
found  to  be  very  large,  especially  transversely,  and  to  weigh  twelve  and  a 
half  ounces.  The  right  auricle  and  ventricle  were  much  distended  with 
dioxk post-mortem  clot;  and  were  both  dilated,  the* ventricle  being  much 
hypertrophied.  The  tricuspid  valve  seemed  to  be  competent,  and  measured 
three  and  a  half  inches  in  circumference.  Its  edges  on  the  auricular  sur- 
face were  fringed  with  papillae  which  measured  about  one-eighth  of  ga  inch 
in  length.  The  left  auricle  was  dilated  and  hypertrophied  to  a  less  iegree 
35 


546  DISEASE   IIST   CHILDEEN. 

than  tlie  left  ventricle.  The  mitral  orifice  was  contracted  to  a  mere  slit, 
with  a  circumference  of  one  inch.  The  pulmonary  artery  was  very  large, 
but  the  valves  were  competent.  The  aortic  orifice  leaked  very  slowly  by 
the  water  test,  but  had  probably  been  competent  during  Hfe.  The  lungs 
and  other  organs  showed  the  usual  signs  of  prolonged  venous  congestion. 

The  heart  was  shown  at  a  meeting  of  the  Pathological  Society  by  my 
colleague,  Dr.  Eadclifie  Crocker.  In  his  comments  upon  the  case,  Dr. 
Crocker  suggested  that  the  basic  systolic  murmur  had  been  probably  due 
to  a  temporary  incompetence  of  the  pulmonary  valves,  owing  to  dilatation 
of  the  artery  from  extreme  congestion  of  the  lungs.  Such  a  cause  for 
pulmonary  regurgitation  is  supported  by  the  authority  of  Hope  and  Hayden. 
The  tricuspid  valve  is  seldom  diseased  primarily.  When  the  seat  of  thick- 
ening or  other  lesion,  it  almost  always  seems  to  be  affected  secondarily, 
being  usually  found,  as  in  the  above  case,  in  connection  with  a  serious 
stricture  of  the  mitral  orifice. 

Adhesion  of  the  layers  of  the  pericardium  is  found  in  not  a  few  cases. 
The  adhesions  are  often  very  thick  and  strong  ;  and  the  lymph  appears  to 
have  penetrated  between  the  muscular  fibres  of  the  heart ;  for  these  are 
often  torn  in  the  attempt  to  separate  the  firmly  attached  serous  membrane. 
Great  hypertrophy  and  dilatation  of  the  organ  usually  accompanies  this 
condition. 

It  is  important  not  to  mistake  for  pathological  beading  of  valves  a 
condition  to  which  Parrot  has  drawn  attention.  According  to  this  ob- 
server, in  a  large  proportion  of  infants  who  die  during  the  first  month 
after  birth,  hsematomata  and  fibrous  nodules  are  found  on  the  auriculo- 
ventricular  valves.  The  hoematomata  are  Httle  spherical  or  conical  tumours 
of  a  dark  purple  or  nearly  black  colour.  In  size  they  may  be  so  small  as 
scarcely  to  be  visible  to  the  unaided  sight,  or  may  reach  the  size  of  a 
millet-seed.  They  are  placed  singly  or  axe  aiTanged  in  groups.  These 
little  projections  are  seated  exclusively  on  the  mitral  and  tricuspid  valves 
at  the  part  where  the  tendinous  cords  are  inserted.  They  lie  close  to  the 
free  edge  of  the  valve,  and  are  covered  by  the  most  superficial  layer  of  the 
endocardium.  In  a  short  time  they  lose  their  colour,  and  sink  down  into 
little  flattened  prominences  before  they  finally  disappear.  They  cease  to 
be  visible  shortly  after  the  end  of  the  first  month  of  life.  Parrot  attributes 
their  origin  to  rupture  of  intravalvular  vessels.  The  fibrous  nodules  oc- 
cupy the  same  situation  as  the  preceding,  and  are  seen  as  httle  flattened 
projections  widened  towards  the  base.  They  are  composed  of  a  dense 
fibro-elastic  tissue.  These  nodules,  especially  the  former,  occur  too  fre- 
quently, and  are  too  harmless  in  their  character,  to  be  ranked  as  patholo- 
gical lesions,  for  no  ill  results  appear  to  follow  their  presence  on  the  valves. 
Strictly  speaking,  no  doubt,  they  are  not  healthy  productions,  but  they 
scarcely  merit  the  name  of  disease. 

The  effect  upon  the  heart's  substance  of  the  morbid  changes  in  the 
valves  is  much  the  same  in  the  child  as  in  the  adult.  Hypertrophy  and 
dilatation  follow,  and  in  severe  cases  may  reach  an  extreme  degree.  In 
the  young  subject  there  is  great  power  of  compensation  ;  and  we  often 
find  that  the  vigour  of  the  heart  becomes  rapidly  increased  so  as  to  make 
up  for  the  valvular  deficiency,  and  the  health  of  the  child  is  seemingly  un- 
impaired. In  examining  the  heart  in  early  hfe  we  must  not  make  the 
mistake  of  attributing  all  murmurs  to  valvialar  imperfection — that  is  to 
say,  to  a  degree  of  imperfection  injurious  to  health.  It  is  more  common 
in  the  child  than  in  the  adult  to  find  a  systohc  murmur  at  the  apex  of  the 
heart,  without  any  other  sign  of  regurgitation  through  the  auriculo-ven- 


CHEONIC   VALVULAE  DISEASE   OF   THE   HEAET.  547 

tricular  opening.  Such  a  murmur  may  persist  for  years,  and  finally  disap- 
pear without  having  led  to  any  alteration  in  the  site  of  the  apex  beat,  or 
other  indication  of  ventricular  hypertrophy.  In  such  cases  there  is. prob- 
ably some  roughening  of  the  surface  of  the  valve,  which,  however,  stUl  re- 
mains perfectly  competent  to  perform  its  functions. 

Symptoms. — A  valvular  lesion  of  the  heart  does  not  necessarily  give 
rise  to  symptoms  of  discomfort ;  and  it  seems  that  in  some  children  years 
can  pass  without  any  sign  of  distress  being  manifested  on  account  of  the 
cardiac  mischief.  It  is  common  to  find  signs  of  valvular  insufficiency  in  a 
child  who  has  been  brought  for  advice  on  account  of  some  casual  derange- 
ment quite  unconnected  with  the  condition  of  the  heart ;  and  even  in 
cases  where  breathlessness  has  been  noticed,  it  is  often  a  recent  symptom, 
while  the  enlargement  of  the  organ  indicates  that  the  valvular  lesion  is  of 
much  more  remote  origin.  When  regurgitation  is  slight,  the  increase  of 
power  quickly  acquired  by  the  heart  compensates  completely  for  the  de- 
fect, and  no  unfavourable  symptoms  are  noticed  until  dilatation  occurs,  or 
a  new  attack  of  endocarditis  aggravates  the  original  imperfection. 

Usually,  the  earUest  and  by  far  the  most  commonly  present  symptom  is 
breathlessness.  It  is  noticed  that  when  the  child  plays  at  any  boisterous 
game,  he  becomes  very  pale,  and-  pants  in  an  unusual  manner.  If  very  pro- 
nounced, the  symptom  may  be  accompanied  by  some  lividity  of  the  lips,  and 
pain  about  the  chest.  In  advanced  cases,  where  much  dilatation  has  ensued, 
orthopnoea  may  be  jDresent,  and  is  a  symptom  of  great  gravity  ;  and  some- 
times attacks  of  syncope  are  noticed.  Palpitation  is  complained  of  in  child- 
hood less  commonly  than  in  adult  life ;  but  if  the  patient  be  anaemic,  the 
heart's  action  may  be  tumultuous  on  slight  exertion.  Ansemia  is  a  fre- 
quent consequence  of  the  more  aggTavated  forms  of  cardiac  lesion.  As  in 
the  adult,  it  is  usually  present  if  there  be  insufficiency  of  the  aortic  valves  ; 
but  even  in  this  case  it  may  not  be  noticeable  as  long  as  the  child  is  kept 
quiet.  A  little  girl  lately  under  my  care,  with  aortic  and  mitral  regurgi- 
tation, always  had  a  good  colour  as  long  as  she  remained  in  the  hospital ; 
indeed,  the  healthiness  of  her  complexion  was  the  subject  of  remark  by 
those  who  were  acquainted  with  the  serious  lesion  under  which  she  was 
labouring. 

Hsemorrhages  sometimes  occur.  The  nose  may  bleed  repeatedly  ;  and 
in  older  children  haemoptysis  may  be  seen,  especially  if  there  be  mitral 
stenosis  as  well  as  regurgitation.  A  little  girl,  aged  twelve  years,  with 
mitral  obstructive  and  regurgitant  disease  and  great  hypertrophy  of  both 
ventricles,  frequently  expectorated  blood.  The  symptom  would  be  prob- 
ably met  with  more  frequently  were  it  not  for  the  childish  habit  of  swal- 
lowing all  sputa  brought  up  from  the  lungs.  Another  common  conse- 
quence of  the  pulmonary  congestion  induced  by  the  valvular  lesion  and 
the  resulting  tendency  to  catarrh,  is  cough.  This  is  usually  short  and  hack- 
ing ;  but  if  loose,  for  the  reason  stated  is  rarely  accompanied  by  expectora- 
tion. When  dilatation  of  the  heart  occurs,  oedema  follows  quickly,  and  the 
disease  then  presents  the  same  distressing  features  which  are  so  famihar 
to  every  one  in  the  case  of  the  adult. 

An  occasional  accident  is  embolism.  This  is  sometimes  the  conse- 
quence of  ulcerative  endocarditis,  disintegrating  particles  of  an  infective 
organic  matter  being  carried  off  into  the  circulation  and  deposited  in  va- 
rious organs,  where  they  produce  the  consequences  known  to  follow  the 
presence  of  such  infarcts.  This  complication,  which  is  accompanied  by 
high  temperature  and  symjptoms  of  blood  contamination,  has  been  already 
referred  to  (see  page  158).     It  appears,  however,  that  an  ulcerative  process 


548  DISEASE  IN   CHILDREN. 

is  not  necessary  to  the  separation  of  portions  of  fibrinous  matter  from  the 
valves.  We  occasionally  meet  with  cases  where  a  child,  the  subject  of  re- 
cog-nised  heart  lesion,  but  making  no  complaint  and  appearing  to  be  Httle 
troubled  by  his  infirmity,  suddenly  becomes  paralysed  on  one  side  from 
obstruction  of  the  middle  cerebral  artery.  The  symptoms  which  accom- 
pany the  onset  of  the  paralysis  vary.  The  child  may  vomit  repeatedly  ;  or 
be  seized  by  convulsions  followed  by  unconsciousness  ;  or  pass  into  a  state 
of  delii'ium  or  even  violent  excitement.  Sometimes  the  emboHsm  takes 
place  more  quietly ;  and  nothing  is  noticed  until  it  is  found  that  the  child's 
face  is  drawn,  and  that  one  side  of  the  body  has  lost  its  power. 

A  little  girl,  aged  six  years,  had  been  subject  for  sixteen  months  to 
shortness  of  breath  after  any  exertion,  and  at  such  times  to  blueness  of  the 
lips.  She  had  never  been  known  to  have  rheumatism  ;  but,  six  months 
before  her  admission  to  the  hospital,  had  had  an  attack  of  measles,  which 
had  been  followed  by  whooping-cough.  There  was  a  suspicious  history 
pointing  to  syphilis,  and  the  child  was  being  treated  by  one  of  my  surgical 
colleagues  for  keratitis.     Her  temperature  was  normal. 

On  May  10th,  the  patient  was  noticed  to  be  dull  and  apparently  sulky. 
She  passed  her  uiine  and  fseces  once  involuntarily,  which  she  had  never 
done  before ;  and  her  temperature  on  that  evening  was  99.6°.  On  the 
next  morning  the  mercury  registered  99.4°,  and  the  child's  mouth  was 
noticed  to  be  drawn  to  the  left  side ;  she  could  not  stand  ;  her  right  arm 
was  completely  useless  ;  and  her  right  eye  closed  imperfectly.  In  addition, 
she  was  aphasic.  Although  drowsy,  she  could  be  easily  roused,  and  she 
took  her  food  well,  having  no  difficulty  in  swallowing. 

On  examination  of  the  heart,  a  loud  systohc  murmur  was  heard  all  over 
the  front  of  the  chest,  and  also  at  the  back  ;  but  it  was  louder  on  the  left 
side,  posteriorly,  than  on  the  right.  In  the  left  axillary  region  it  was  well 
heard,  but  became  greatly  diminished  in  intensity  at  the  posterior  axillary 
line.  In  front,  the  pitch  of  the  murmur  was  highest  at  the  base  of  the 
heart,  and  fell  perceptibly  towards  the  left  nipj)le  ;  but  in  intensity  of  sound 
there  was  httle  difference  between  the  nipjple  and  the  upper  part  of  the 
sternum. '  The  jDoint  of  maximum  intensity  appeared  to  be  the  pulmonary 
valves.  The  apex  beat  was  in  the  fifth  intersj)ace  in  the  nipple  line,  and  the 
right  border  reached  nearly  a  finger's  breadth  beyond  the  right  margin  of 
the  sternum.  There  was  no  clubbing  of  the  fingers  nor  any  signs  of  cya- 
nosis, at  lea*st  while  the  child  was  at  rest.  That  evening  (May  11th)  the 
temperature  was  101.4°. 

On  May  12th  (the  second  day  of  the  paralj^sis),  the  temperature  was 
101.6°  at  8  A.M.,  and  rose  in  the  evening  to  103.8°.  The  incontinence  of 
urine  still  continued,  and  the  paralysis  and  aphasia  remained  the  same. 
The  child  was  perfectly  conscious  and  intelligent,  and  tried  in  vain  to 
speak.  Her  tongue,  when  protruded,  deviated  to  the  right  side ;  the  right 
arm  and  leg  were  perfectly  flaccid,  and  their  sensibility  was  diminished. 
The  muscles  responded  well  to  the  internipted  current.  The  temperature 
fell  somewhat  on  the  third  day  of  the  paralysis,  but  remained  more  elevated 
than  natural,  in  the  evening,  for  several  weeks,  with  occasional  rises.  Thus, 
on  one  or  two  occasions  it  suddenly  rose  to  102°  ;  and  on  one  occasion  to 
104°,  in  the  evening,  and  then  quickly  became  normal.  During  the  child's 
stay  in  the  hospital  there  was  no  sign  of  embolism  of  other  organs.  Her 
right  leg  rapidly  improved,  and  she  regained  the  power  of  walking ;  but 
the  arm  continued  powerless,  and  when  discharged  on  August  14th,  the 
patient  was  still  unable  to  speak. 

In  this  girl  there  was  doubtless  a  congenital  lesion  of  the  heart,  consist- 


CHEON-IC   VALVULAK  DISEASE   OF   THE  HEART.  549 

ing  in  part  of  narrowing  of  the  pulmonary  artery,  and,  as  a  consequence, 
the  right  side  of  the  heart  had  become  hypertrophied.  It  is  probable, 
also,  that  there  was  insufficiency  of  the  mitral  valve,  from  endocarditis 
occurring  after  birth  ;  and  that  it  was  from  this  source  the  embolus  was 
derived,  which  had  become  arrested  in  the  middle  cerebral  artery. 

In  another  case,  a  boy,  aged  eleven  years,  who  was  suffering  from  steno- 
sis and  insufficiency  of  the  mitral  orifice,  was  taken  suddenly  with  paralysis 
of  the  right  side,  combined  with  difficulty  of  speech,  while  recovering  from 
fin  attack  of  small-pox. 

It  is  not  always  in  the  arteries  of  the  brain  that  the  embolus  is  arrested. 
The  fragment  may  lodge  in  the  kidney,  producing  albuminuria;  in  the 
liver,  causing  enlargement  and  slight  jaundice  ;  and  in  the  spleen,  leading 
to  perceptible  swelling  of  the  organ.  In  tjie  latter  case,  according  to  Dr. 
Gee,  the  infarction  is  peculiarly  liable  to  be  associated  with  fever  of  the 
hectic  type,  without  the  endocarditis  to  which  it  is  owing  being  necessarily 
ulcerative. 

There  is  one  other  result  of  embolism  which  may  be  noticed,  although 
its  consequences  are  not  so  immediately  obvious.  Aneimsmal  dilatations 
in  the  child  are  now  known,  from  the  researches  of  Dr.  J.  W.  Ogle  and 
others,  to  be  due  to  this  accident.  Aneurisms  seated  on  the  small  arteries 
of  the  brain,  leading  to  fatal  hemorrhage,  sometimes  occur  in  young  sub- 
jects, and  are  doubtless  to  be  attributed  to  plugging  of  the  vessel  by  this 
means.  The  same  condition  is  also  occasionally  seen  in  the  larger  arteries, 
as  the  external  iliac. 

Besides  embolism,  other  occasional  complications  may  be  observed  in 
cases  of  heart  disease.  On  account  of  the  rheumatic  disposition  of  the 
majority  of  such  patients,  evidences  of  that  constitutional  state  are  often 
observable.  Skin  eruptions,  especially  eczema,  erythema,  and  urticaria,  are 
common  ;  pleurisy  and  pericarditis  are  not  unfrequent  lesions  ;  and  joint 
pains  are  often  complained  of.  Another  common  complication  is  some 
form  of  nervous  derangement.  Chorea  is  hable  to  occur  in  the  subjects  of 
heart  disease  ;  and  Dr.  Sansom  has  remarked  the  occasional  association  of 
epilepsy  with  cardiac  mischief.  In  some  cases,  impairment  of  nutrition  is 
the  only  evidence  of  ill  health.  A  little  boy,  aged  seven  years,  was  brought 
to  the  hospital  with  signs  of  mitral  stenosis  and  insufficiency.  Still,  the 
boy  had  no  cough,  and  did  not  appear  to  be  breathless  on  exertion.  For 
six  months,  however,  he  had  been  persistently  wasting,  although,  with  the 
exception  of  occasional  abdominal  pains,  there  was  no  evidence  of  digestive 
d.erangement,  or  other  sufficient  cause  for  the  impaired  state  of  his  nutri- 
tion. In  some  cases  the  wasting  is  combined  with  ansemia,  which  may  even 
reach  an  extreme  degree. 

The  most  common  form  of  heart  lesion  met  with  in  childhood  is  regur- 
gitation through  the  mitral  orifice.  Next  in  order  of  frequency  is  regur- 
gitant combined  with  constrictive  disease.  Then  f oUoav  a  combination  of 
constrictive  and  regurgitant  disease  of  the  aortic  orifice,  and  constrictive 
disease  alone.  Stenosis  of  the  mitral  orifice,  unaccompanied  by  insuffi- 
ciency of  the  valve,  is  not  common  in  the  child  ;  and  regurgitation  through 
the  aortic  orifice  is  far  rarer  than  it  becomes  in  after-life  years.  It  will  be 
unnecessary  to  describe  the  physical  signs  and  special  syraptoms  connected 
with  these  various  lesions,  since  they  do  not,  as  a  rule,  present  any  peculi- 
arities dependent  upon  the  early  age  of  the  patient.  With  regard,  how- 
ever, to  a,ortic  regurgitant  disease,  it  may  be  remarked  that  this  form  of 
heart  lesion,  as  has  been  j^reviously  stated,  is  not  always  accompanied  in 
the  child  by  any  striking  pallor  of  the  complexion ;  nor  is  it  often  indi- 


550  DISEASE  m   CHILDREN. 

cated  by  any  marked  alteration  of  the  pulse.  The  pulse  is  regular,  and  is 
weakened  by  raising  the  hand  above  the  head  ;  but  the  characteristic 
hammer-Hke  beat  of  the  artery  is  usually  absent.  Moreover,  the  pulsation 
of  the  more  superficial  vessels,  although  visible  if  narrowly  looked  for,  is 
seldom  sufficiently  marked  to  catch  the  eye  unsought. 

Terminations. — When  death  occurs  in  cases  of  heart  disease,  during 
childhood,  the  fatal  event  is  often  brought  about  by  some  inflammatory 
compHcation.  Children  so  afflicted  are  more  weakened  than  is  the  case 
with  a  healthy  subject,  by  casual  derangements,  and  have  less  vigour  vdth 
which  to  bear  up  against  a  serious  disease.  When  death  is  due  directly  to 
the  heart  lesion,  it  generally  occurs  in  cases  where  the  pericardium  has 
become  firmly  adherent  to  the  substance  of  the  heart,  and  has  led  to  serious 
interference  with  the  nutrition  of  the  organ.  The  cavities  become  greatly 
dilated,  and  the  feeble  walls  are  no  longer  equal  to  the  discharge  of  their 
functions.  Great  congestion  of  the  lungs  follows,  and  there  is  general 
stasis  of  blood  in  the  systemic  venous  system,  with  its  inevitable  conse- 
quences. In  most  cases  of  death  from  cardiac  dropsy,  the  pericardium  is 
found  firmly  adherent  to  the  heart. 

Sudden  death  is  not  very  common  from  cardiac  lesion  in  the  child.  When 
it  takes  place  it  is  probably  the  result  of  clotting  of  blood  in  the  large  ves- 
sels of  the  heart.  A  little  girl  was  under  my  care  in  the  East  London 
Children's  Hospital  for  chorea,  which  had  followed  closely  upon  an  attack 
of  sub-acute  rheumatism.  The  child  was  low  and  depressed,  and  her  com- 
plexion was  markedly  anaemic.  The  choreic  movements  were  bilateral, 
affecting  the  face,  tongue,  and  eyes,  but  were  only  moderate  in  degree. 
When  she  took  food  into  her  mouth,  the  muscles  of  deglutition  acted  con- 
vulsively. On  examination  of  the  heart  there  was  a  loud  bellows  murmur 
at  the  apex,  conducted  well  into  the  axilla.  This  evidently  dated  from 
some  previous  attack  of  rheumatism.  During  the  girl's  stay  in  the  hos- 
pital, fibrous  nodules  were  developed  on  the  tip  of  each  spinous  process  of 
the  vertebrse.  The  child  was  treated  at  first  with  chloral ;  afterwards,  with 
quinine  and  iron.  She  took  three  oimces  of  port  wine  daily.  In  spite  of 
the  treatment,  she  wasted,  and  seemed  to  grow  weaker.  Aiter  a  time,  as 
no  improvement  occurred,  the  patient  was  removed  by  her  friends  ;  and  we 
afterwards  heard  that  she  died  quite  suddenly  on  the  following  day.  No 
post-mortem  examination  was  obtained. 

Sometimes  the  clotting  takes  place  more  slowly.  A  little  boy,  suffering 
from  mitral  regurgitant  disease,  with  much  dilated  hypertrophy  of  the  left 
ventricle,  was  noticed  for  two  days  to  be  uneasy  and  restless,  with  some 
duhiess  of  manner.  On  the  thkd  day  he  was  seized  with  dyspnoea,  which 
became  gradually  more  severe.  The  child  grew  excessively  restless,  an,d 
threw  himself  about  in  his  bed.  When  I  saw  him  (at  3  p.m.)  he  was  sitting 
up  in  bed,  supported  by  the  nurse.  His  eyes  were  staring  and  wild-look- 
ing, his  face  much  congested,  his  lips  and  cheeks  purple,  his  finger-nails 
blue.  The  breathing  was  laborious,  and  the  nares  acted.  The  heart's  ac- 
tion was  excited  and  forcible,  but  the  pulse  at  the  wrist  was  excessively 
weak.  The  boy  was  very  restless,  constantly  changing  his  position  and 
throwing  his  arms  about.     He  was  quite  sensible,  and  made  no  complaint. 

Six  leeches  were  appHed  to  the  region  of  the  heart.  They  bled  freely, 
but  the  symptoms  continued,  the  lividity  deepened,  and  the  boy  died  in  a 
few  hours.  No  examination  of  the  body  was  allowed  ;  but  there  can  be 
little  doubt  that  death  was  occasioned  by  ante-mortem  clotting  in  the 
heart  or  large  vessels  near  their  origin. 

Diagnosis. — The  existence  of  a  valvular  lesion  of  the  heart  is  ascertained 


CHROISriC   VALVULAR   DISEASE  OF   THE  HEAET.  551 

almost  as  readily  in  the  young  subject  as  it  is  in  the  adult.  Even  if  a 
child  cry  during  the  examination  of  his  chest,  the  heart  sounds  can  usually 
be  perceived  during  the  short  interval  of  inspiration.  In  most  cases,  hovs^- 
ever,  if  the  patient  be  not  frightened  by  abruptness  of  movement,  and  if 
he  be  allowed  to  play  with  the  stethoscope  before  the  instrument  is  applied 
to  his  chest,  a  young  child  will  submit  to  the  process  of  auscultation  with' 
out  any  complaint. 

When  a  murmur  is  detected,  we  have  to  decide  if  it  be  of  recent  origin. 
A  recent  murmur  is  soft  and  of  low  pitch ;  but  as  time  goes  on  it  becomes 
harsher  and  its  pitch  rises.  If  the  lesion  affect  the  cahbre  of  the  orifice  at 
which  it  is  generated,  or  interfere  with  the  closure  of  the  valves,  it  soon 
leads  to  some  enlargement  of  the  heart  and  alteration  in  the  position  of 
the  apex-beat.  If,  in  a  child  who  is  suffering  from  acute  or  sub-acute 
rheumatism,  we  detect  a  harsh,  high-pitched,  systoUc  murmur  at  the  apex, 
we  may  conclude  that  the  cardiac  lesion  dates  from  a  period  considerably 
anterior  to  the  existing  illness.  In  noting  the  position  of  the  apex-beat, 
and  its  relation  to  the  nipple,  it  is  important  to  remember  that  in  many 
children  the  nipple  lies  at  a  lower  level  in  the  chest  than  is  the  case  in  the 
adult.  Instead  of  the  fourth  rib,  it  is  often  placed  on  the  upper  border  of 
the  fifth.  In  such  a  subject  the  normal  position  of  the  apex-beat  would  be 
in  the  fifth  interspace  just  below  the  nipple  and  sHghtly  to  its  inner  side. 

In  every  case  of  indisposition  in  the  child,  however  apparently  trifling 
it  may  seem,  the  heart  should  be  carefully  examined,  for,  as  has  been  said, 
a  valvular  lesion  may  be  present  without  giving  rise  to  symptoms  of  dis- 
comfort, and  evidence  of  disease  is  sometimes  found  very  unexpectedly. 
There  are,  however,  certain  combinations  of  symptoms  which  should  at 
least  excite  suspicion.  Attacks  of  palpitation  in  the  child  are  less  com- 
monly than  in  the  adult  the  consequence  of  functional  derangement  or 
dyspeptic  disorder,  and,  if  present  in  a  marked  degree,  should  suggest 
cardiac  mischief.  Frequent  epistaxis  in  an  anaemic  child  is  not  uncom- 
monly the  result  of  mitral  disease  ;  and  if  a  child  who  is  not  anaemic 
becomes  breathless  after  exertion,  especially  if  the  shortness  of  breath  is 
accompanied  by  hvidity  of  the  lips,  the  symptom  should  excite  the  strongest 
suspicions. 

The  presence  of  a  murmur  at  the  apex  is  not  in  itself  sufficient  evidence 
of  a  serious  lesion.  Heart  murmurs  in  children  not  uncommonly  disappear. 
This  statement  is  time  not  only  of  recent  soft  murmurs,  such  as  are  heard 
in  cases  of  chorea  or  acute  rheumatism,  but  also  of  louder  and  harsher 
murmurs  which  are  known  to  be  of  longer  duration.  In  all  cases  where  a 
harsh  murmur  is  detected,  signs  of  hypertrophy  of  the  left  ventricle  should 
be  searched  for.  If  no  enlargement  be  discovered,  and  the  apex-beat  re- 
main in  its  normal  position,  it  is  highly  improbable  that  any  serious  val- 
vular defect  is  present  (see  page  163).  "  The  apex-beat  of  the  heart  may, 
however,  be  in  an  abnormal  position  without  the  alteration  in  site  being 
the  result  of  endocardial  disease.  The  causes  which  lead  to  displacement 
of  the  organ  are  referred  to  elsewhere  (see  page  402). 

Again,  a  basic  heart  murmur  may  be  produced  by  causes  acting  from 
without.  Pressure  upon  the  large  vessels  by  caseous  bronchial  glands 
may  so  narrow  the  channel  as  to  give  rise  to  a  systolic  murmur.  In  these 
cases,  however,  other  signs  will  be  found,  explanatory  of  the  abnormal 
phenomenon  (see  page  181). 

The  detection  of  a  cardiac  murmur  will  sometimes  furnish  an  explana- 
tion of  symptoms  which  would  be  otherwise  obscure.  In  all  cases  where 
hemiplegia  occurs  suddenly  in  a  child,  attention  should  be  at  once  directed 


5o2  DISEASE   II^   CHILDEEIS'. 

to  the  heart.     But  mere  pyrexia  is  sometimes  caused  by  embolism  in  other 

organs,  where  irritation  and  disturbance  give  rise  to  less  characteristic 
symptoms  than  are  found  when  a  portion  of  brain  is  suddenly  rendered 
useless.  In  cases  of  ulcerative  endocarditis,  continued  high  temperature, 
and  a  condition  bearing  a  close  resemblance  to  enteric  fever,  may  be  in- 
duced by  the  accident ;  but  even  when  the  fragments  of  organic  matter 
thrown  off  from  the  valves  have  not  this  infective  character,  an  UTCgular 
pyrexia  may  be  set  up.  Careful  search  in  these  cases  will  often  discover 
some  local  symptoms  suggestive  of  the  presence  of  an  infarct.  The  spleen 
may  be  found  to  be  swollen  ;  the  hver  may  be  enlarged,  with  slight  jaun- 
dice ;  albuminuria  may  occur  from  embolism  of  a  kidney ;  or  petechise 
may  be  noticed  in  the  skin  from  obstruction  to  the  cii-culation  through  the 
cutaneous  capillaries.  In  all  these  cases  the  source  of  the  mischief  will  be 
discovered  on  examination  of  the  heart. 

Prognosis. — As  long  as  the  cardiac  lesion  gives  rise  to  no  symptoms,  the 
prognosis  is  very  favourable.  If  a  mitral  murmui*,  although  hai-sh  in  qual- 
ity and  high  in  j^itch,  be  accompanied  by  no  signs  of  hypertrophy  of  the 
left  ventricle,  there  is  reason  to  hope  that  it  may  ultimately  disappear.  If 
signs  of  enlargement  of  the  heart  are  noticed,  we  cannot  expect  that  the 
valvular  lesion  will  be  recovered  from  ;  for  a  temporary  dilatation  of  the 
left  ventricle,  such  as  is  apt  to  occur-  in  chlorotic  girls,  I  do  not  think  is 
common  in  the  child ;  but  as  long  as  the  health  of  the  patient  seems  to 
suffer  in  no  way  from  the  disease,  little  apprehension  of  immediate  danger 
need  be  entertained.  Directly,  however,  any  symptoms  are  noted  indi- 
cating impairment  of  nutrition  or  obstruction  to  the  cii-culation,  there  is 
cause  for  anxiety.  Serious  breathlessness,  li^idity  on  slight  exertion, 
marked  anaemia  and  perceptible  loss  of  ilesh,  are  all  unpromising  symptoms. 

The  prognosis  is  more  favourable  in  cases  of  mitral  insufficiency  than 
of  mitral  stenosis.  If  the  mitral  disease  has  led  to  tricuspid  insufficiency, 
speedy  dilatation  of  the  ca-^ities  of  the  heart  may  be  anticiiDated.  '\Mien 
signs  of  di'opsy  begin  to  be  perceived,  the  danger  is  reaUy  imminent.  By 
judicious  treatment  and  careful  nui-sing  the  end  may  be  postjooned,  but 
cannot  in  any  case  be  far  distant. 

Attacks  of  rheumatism  and  chorea,  being  apt  to  aggravate  the  vahailar 
lesion,  are  greatly  to  be  dreaded  ;  and  aU  forms  of  inflammatory  chest 
affection,  as  they  increase  the  work  of  the  heart,  are  likely  to  have  injurious 
consequences.  Embohsm  is  a  very  serious  accident.  If  the  embolus 
lodge  in  the  middle  cerebral  artery  and  produce  hemiplegia,  the  complica- 
tion, although  it  may  not  destroy  hfe,  may  lead  to  permanent  impairment 
of  movement  of  the  hmbs.  In  the  second  of  my  cases  of  cerebral  embolism 
referred  to  above — a  boy  eleven  years  old — the  patient,  two  years  after  the 
attack  of  paralysis,  had  very  little  use  of  the  right  arm.  He  could  walk, 
however,  and  had  recovered  the  power  of  speech.  If  the  brain  be  un- 
affected, and  the  embohsm  occm-  in  other  organs,  the  resulting  iiTitation 
and  disturbance  may  prove  fatal,  even  although  the  fragment  detached 
from  the  valve  be  destitute  of  any  infective  property. 

Treatment. — In  cases  where  a  valvular  lesion  exists  without  producing 
any  sign  of  inconvenience,  there  is  no  reason  for  special  medication.  The 
parents  should,  howevei",  be  cautioned  to  spare  the  child  all  unnecessary 
fatigue,  and  to  prevent  him  as  much  as  possible  from  taking  pai-t  in  violent 
exercises.  Excitement  of  the  heart  should  be  prevented.  In  the  case  of 
a  schoolboy  this  is,  of  course,  a  matter  of  great  difficulty  ;  for,  as  long  as 
the  child  is  untroubled  by  uneasy  sensations,  he  cannot  be  convinced  of  the 
necessity  for  quiet.    Little  girls  are  fortunately  less  addicted  to  boisterous 


CHRONIC   VALVULAE  DISEASE   OF  THE   HEART.  553 

games.  Measures  should  be  taken  to  prevent  fresh  attacks  of  rheu- 
matism, and  the  child  should  wear  woollen  underclothing  all  the  year 
round. 

Directly  palpitations,  breathlessness  after  exertion,  or  ansemia,  begin  to 
be  noticed,  more  active  measures  must  be  taken.  Too  energetic  action  of 
the  heart  must  be  quieted  by  digitalis.  This  valuable  drug  has  always 
seemed  to  me  to  be  well  borne  by  young  patients.  The  best  form  in  which 
it  can  be  given  is  the  infusion,  of  which  a  child  of  ten  years  old  will  take, 
without  any  inconvenience,  two  drachms  three  times  in  the  day.  On  ac- 
count of  the  importance  in  these  cases  of  keeping  up  a  gentle  action  of  the 
bowels,  I  usually  combine  the  remedy  with  a  mild  aperient  and  a  vegetable 
bitter.  One  drachm  each  of  the  infusions  of  digitalis,  senna,  and  calumba, 
given  three  times  a  day  before  meals,  is  often  followed  by  great  benefit ; 
or,  if  desired,  the  proportion  of  digitalis  may  be  doubled.  If  the  diges- 
tion is  weak,  a  few  drops  of  dilute  nitric  acid  may  be  added  to  the 
draught.  When  any  signs  of  ansemia  are  present,  iron  should  be  given 
in  addition.  This  medicine  is  best  administered  separately,  and  I  pre- 
fer the  exsiccated  sulphate  in  these  cases  to  all  other  forms  of  iron.  Four 
or  five  grains  of  the  salt  may  be  given  in  glycerine  directly  after  each 
meal. 

Great  care  is  necessary  in  the  matter  of  diet.  The  child  is  not  to  be 
overloaded  with  food  because  he  is  weakly  and  seems  to  be  losing  flesh. 
His  meals  should  be  small,  that  his  stomach  may  not  be  oppressed  ;  and  the 
quantity  allowed  should  be  such  as  his  digestion  can  bear  and  his  tissues 
readily  assimilate.  If  the  blood  be  overcharged  with  superabundant 
material  which  is  useless  for  purposes  of  nutrition,  extra  work  is  thrown 
upon  the  excretory  organs,  whose  duty  it  is  to  eliminate  it  from  the  system. 
It  is  well  to  order  four  small  meals  in  the  day,  of  which  one  may  consist 
of  meat  with  vegetables,  a  second  of  a  piece  of  fish  or  an  egg,  and  the  two 
others  of  milk  and  bread  and  butter.  The  quality  of  the  food  should  be 
also  attended  to.  All  rheumatic  subjects  have  a  special  tendency  to  flatu- 
lence and  acidity  ;  and  this  tendency  is  favoured  by  excess  of  starchy  mat- 
ters and  sweets.  It  is  often  remarkable  to  note  the  immediate  improve- 
ment which  takes  place  in  the  condition  of  a  child  who  has  been  pampered 
and  overfed  "  because  he  is  clehcate,"  when  these  simple  rules  are  at- 
tended to. 

When  dilatation  of  the  heart  occurs,  and  leads  to  stasis  of  blood  in  the 
systemic  veins  and  general  oedema,  diiu^etics  are  indicated.  This  condi- 
tion must  be  treated  in  the  child  upon  the  same  principles  as  are  followed 
in  the  case  of  the  adult.  The  kidneys  must  be  stimulated  to  act  by  the 
acetates  of  potash  and  ammonia,  spirits  of  nitrous  ether,  juniper,  fresh 
broom  tops,  squill  and  digitalis.  One  especially  valuable  diuretic  in  these 
cases  is  the  tincture  of  cantharides.  I  have  seen  a  formidable  amoxmt  of 
dropsy  clear  away  completely  in  a  child  of  nine  years  old  under  the  influ- 
ence of  ten  drops  of  this  remedy  given  three  times  a  day,  after  other 
means  had  been  used  without  making  any  impression  upon  the  effusion. 
I  have  tried  the  resin  of  copaiba,  but  the  drug  has  proved  of  little  service 
in  my  hands.  Drs.  Leech  and  Brackenridge  speak  highly  of  the  value  of 
caffein.  The  action  of  diuretics  is  greatly  aided  by  dry-cupping  the  region 
of  the  kidneys,  and  afterwards  applying  a  succession  of  hot  linseed-meal 
poultices  to  the  loins.  For  aperients,  I  prefer  the  compound  jalap  powder 
to  elaterium,  which  has  a  very  uncertain  action  on  the  child.  Stimulants 
are  of  service,  and  unsweetened  gin  may  be  given  in  suitable  doses  as  re- 
quired.    If  it  be  necessary  to  puncture  the  legs.  Dr.  Southey's  cannulse 


554  DISEASE   IN   CHILDEEN. 

should  be  employed  ;  and  Dr.  Goodhart's  suggestion  that  these  instru- 
ments should  be  steeped  in  some  boiling  germicide  before  being  used^  is 

one  of  distinct  practical  value. 

When  emboUsm  occtu's  in  a  cerebral  artery,  producing  hemiplegia,  the 
bisulphite  of  soda  may  be  given  in  doses  of  ten  or  fifteen  grains  three 
times  a  day.  This  drug  has  a  marked  action  in  rapidly  relieving  the 
phlebitis  which  is  so  common  in  women  lately  dehvered  ;  but  my  experi- 
ence is  too  small  to  enable  me  to  speak  confidently  of  its  value  in  the 
cases  above  referred  to. 


art  S, 
DISEASES   OF   THE   MOUTH   AND   THROAT, 


CHAPTER  L 

THE   DERANGEMENTS   OF   TEETHING. 

The  period  of  active  development  of  the  milk  teeth  is  always  a  time  of 
trial  for  the  young  chUd.  Many  an  infant  seems  healthy  and  sturdy  up 
to  this  point ;  but  when  the  time  of  teething  arrives  his  nutrition  falters 
and  he  begins  to  fail.  On  this  account  mothers,  if  they  do  not  look  upon 
the  eruption  of  the  teeth  as  a  disease  in  itself,  are  at  least  in  the  habit  of 
attributing  every  complaint  which  occurs  during  the  first  two  years  of  Ufe 
to  the  influence  of  this  normal  physiological  process.  In  the  medical  pro- 
fession the  views  held  with  regard  to  the  influence  exercised  by  teething 
upon  the  infant  economy  were  at  one  time  very  similar.  At  the  beginning 
of  this  century,  dental  development  was  looked  upon  as  one  of  the  chief 
causes  of  death  in  the  infant.  One  author  classes  it  amongst  the  fatal  dis- 
eases of  childhood.  Others  estimate  the  mortahty  from  this  cause  at  one- 
tenth,  one-sixth,  one-third,  and  even  one-haK  of  the  whole  number  of 
deaths  under  the  age  of  two  years.  Even  in  the  present  day  it  is  common 
to  find  dentition  included  in  the  etiology  of  almost  every  variety  of  nervous 
disorder  occurring  in  the  child. 

The  period  of  dentition  coincides  with  that  of  the  most  active  physical 
progress.  Towards  the  end  of  the  first  year  of  hfe  the  follicular  apparatus 
of  the  intestines  is  undergoing  considerable  development ;  the  cerebro- 
spinal system  is  passing  through  a  stage  of  rapid  growth  and  high  func- 
tional activity  ;  and  most  organs  and  tissues  of  the  body  are  in  a  state  oi 
active  change.  The  evolution  of  the  teeth  is  not,  therefore,  a  soUtary  in- 
stance of  developmental  progress,  but  corresponds  to  a  similar  activity  of 
growth  in  other  parts.  No  doubt,  a  period,  such  as  this,  of  quick  transi- 
tion is  a  period  of  exceptional  susceptibility.  Derangements  of  function 
are  very  liable  to  occur  ;  but  to  attribute  these  exclusively  to  one  of  the 
many  physiological  processes  of  which  the  body  is  the  seat,  merely  because 
this  process  is  external  and  visible  to  the  eye,  while  the  others  are  inter- 
nal and  cannot  be  seen,  is  to  generalize  hastily,  and  from  very  insufficient 
data. 

There  is  another  reason  why,  at  the  time  of  teething,  various  forms  of 


556  DISEASE  iisr  childkeist. 

illness  are  liable  to  arise.  The  stomatitis  so  commonly  induced  by  the 
advance  of  a  tooth  in  the  gum,  is  a  cause  of  pyrexia.  A  feverish  child  is 
very  susceptible  to  chills,  and  is  liable  to  be  disordered  by  the  irritating 
influence  of  unsuitable  food.  In  such  a  state,  also,  the  digestive  power  of 
the  infant  is  v^eakened,  so  that  the  food  on  which  he  has  been  thriving 
may  cease  to  agree.  Derangements  of  the  stomach  and  bowels,  thus  in- 
duced, if  prolonged  as  they  often  are  by  improper  treatment,  cause  serious 
interference  with  nutrition  and  not  uncommonly  bring  the  infant  to  the 
grave.  To  say,  however,  that  in  such  a  case  the  child  dies  from  teething, 
is  incorrect.  He  dies  from  mal-nutrition,  brought  on  by  persistence  in 
forcing  upon  him  food  which  is  no  food,  because  he  cannot  digest  it.  His 
diet,  instead  of  supplying  him  with  the  nourishment  he  requires,  ferments, 
turns  acid,  and  sets  up  catarrhal  diarrhoea ;  so  that  at  last  he  succumbs, 
worn  and  exhausted  by  purging  and  starvation.  The  looseness  of  the 
bowels,  which  is  so  apt  to  occur  during  the  period  of  teething,  cannot  be 
attributed  with  any  justice  directly  to  the  process  of  dentition.  The  fever- 
ish child  is  attacked  by  intestinal  catarrh,  because  his  body  for  the  time 
is  more  than  usually  susceptible  to  the  influences  which  are  capable  of  ex- 
citing that  derangement ;  but  teething  is  the  cause,  not  of  the  purging,  but 
of  the  fever.  So,  also,  in  the  case  of  pulmonary  catarrh,  which  in  some 
subjects  is  a  common  accompaniment  of  the  eruption  of  each  separate 
tooth,  it  is  to  the  pyrexia,  and  not  to  the  accidental  cause  of  the  pyrexia, 
that  the  derangement  is  to  be  ascribed.  In  support  of  this  view,  it  may  be 
remarked  that  diarrhoea  is  a  more  common  complication  of  dentition  dur- 
ing the  warmer  months,  when  the  weather  is  liable  to  sudden  and  unex- 
pected changes,  and  the  temperature  varies  rapidly  while  the  dress  of  the 
child  remains  the  same  ;  and  is  less  common  during  the  winter,  when  more 
care  is  taken  to  guard  the  child's  body  from  the  cold.  Again,  the  pulmo- 
nary accidents  are  more  common  in  raw,  damp  weather,  at  the  times  when 
such  disorders  are  especially  apt  to  prevail. 

On  account  of  the  early  age  of  the  infant,  and  for  the  reasons  which 
have  been  given,  the  first  dentition  is  more  liable  than  the  second  to  be  ac- 
companied by  serious  disturbances  ;  but  even  in  cutting  the  second  crop 
of  teeth,  digestive  troubles  are  likely  to  occur,  as  will  be  afterwards  de- 
scribed. 

The  Jirst  dentition  begins  rmder  normal  conditions  in  the  middle  of  the 
first  year,  and  ends  toward  the  beginning  of  the  third.  The  eruption  of 
the  milk  teeth  may,  however,  be  anticipated  or  delayed  through  individual 
peculiarity,  or  some  abnormal  constitutional  state.  Thus,  cases  occasionally 
occur  in  which  the  child  is  found  to  have  a  tooth  when  he  is  born.  Such 
teeth  are  usually  sharp  and  hook-shaped,  and  are  often  loose,  consisting 
merely  of  the  crown  of  the  tooth  embedded  in  a  fold  of  the  gum.  Henoch 
has  described  another  variety  of  congenital  tooth,  which  is  firmly  fixed  in 
the  socket.  The  tooth  is  destitute  of  enamel,  and  looks  yellow,  with  a 
rough  surface.  Henoch  attributes  the  eruption  to  a  periostitis  of  the  al- 
veolar border,  which  pushes  the  rudimentary  tooth  outwards  by  swelling 
and  exudation  within  the  socket. 

It  is  not  uncommon  for  teeth  to  begin  to  be  cut  at  the  third  or  fourth 
month  ;  but  in  such  cases  the  eruption  of  one  or  two  teeth  is  usually  fol- 
lowed by  a  pause,  and  the  continuance  of  the  process  is  deferred  until  the 
usual  age.  In  certain  states  of  the  constitution,  dentition  is  early.  Thus, 
children  with  tubercular  tendencies,  or  who  sulfer  from  a  syphilitic  ca- 
chexia, cut  theu'  teeth  early,  as  a  rule.  In  rickets,  on  the  contrary,  denti- 
tion is  always  late,  and  in  excejjtional  cases  no  tooth  may  appear  until  the 


DEEA]SrGEME]SrTS   OF   TEETHING.  557 

end  of  the  second  or  beginning  of  the  third  year.  Ordinary  mahiutrition, 
when  the  child  has  not  become  rickety,  does  not  interfere  with  the  evolu- 
tion of  the  milk  teeth.  In  chronic  diarrhoea,  when  the  child  is  very  weakly, 
and  much  wasted  by  constant  purging,  I  have  often  noticed  with  surprise 
that  the  natiu'al  evolution  of  the  teeth  has  been  in  no  way  retarded  by  the 
distressing  complaint. 

In  an  ordinary  case  the  milk  teeth  appear  in  the  following  order : — 
Lower  central  incisors,  upper  central  incisors,  upper  lateral  incisors,  lower 
lateral  incisors,  first  molars,  canines,  back  molars.  Of  these  the  first 
should  appear  between  the  seventh  and  ninth  month.  At  twelve  months 
old  the  infant  should  have  cut  eight  teeth,  and  the  four  first  molars  should 
be  in  process  of  evolution.  He  should  cut  his  eye-teeth  (canines)  between 
the  sixteenth  and  twentieth  month ;  and  the  whole  number  of  the  first 
•crop  (twenty)  should  have  pierced  the  gum  soon  after  the  end  of  the  second 
year.  The  teeth  are  usually  cut  in  pairs  ;  and  after  the  completion  of 
each  group  there  is  usually  a  pause  before  the  evolution  of  the  next  group 
begins. 

The  order  given  above,  although  that  which  most  commonly  obtains, 
is  yet  often  departed  from  in  children  whose  health  is  perfectly  good. 
Many  babies  cut  their  teeth  "cross,"  as  it  is  called.  The  lateral  incisors 
sometimes  appear  before  the  central  front  teeth  ;  the  first  molars  may 
precede  the  lateral  incisors  ;  the  last  molars  may  precede  the  canines  ;  and 
in  a  few  instances  I  have  seen  a  canine  tooth  cut  before  any  of  the  first  mo- 
lars have  appeared,  but  this  last  exception  is  a  very  rare  one.  Sometimes 
in  rickety  children,  when  dentition  is  greatly  retarded,  the  first  tooth  to 
appear  is  one  of  the  first  molars.  Thus,  a  rickety  little  boy  under  my  care 
cut  his  first  tooth — one  of  the  first  molars — at  the  age  of  two  years.  An- 
other cut  his  earhest  tooth — also  a  fii'st  molar — at  fifteen  months. 

Although  the  full  number  of  the  milk  teeth  when  dentition  is  completed 
is  twenty,  this  number  is  not  always  reached.  It  may  happen  that  certain 
teeth  never  appear  at  all.  Thus,  a  little  girl  under  my  care,  aged  two 
years  and  nine  months,  was  seen  to  have  all  the  milk  teeth  except  the  two 
upper  lateral  incisors.  On  the  left  side  there  was  a  narrow  space  re- 
maining between  the  left  middle  incisor  and  the  canine  ;  but  in  this  space 
the  gum  was  sharp,  and  there  was  no  sign  of  a  tooth.  On  the  right  side, 
the  right  central  incisor  and  the  adjoining  canine  were  in  contact.  In  the 
same  way  I  have  known  the  whole  four  canines  to  be  absent.  In  some 
cases  the  pecuharity  is  a  hereditary  one.  In  a  case  which  came  under  my 
notice  the  left  lower  lateral  incisor  was  wanting  in  a  httle  girl  of  two  years 
old.  The  same  incompleteness  of  the  milk  teeth  had  occiu'red  in  the 
mother.  This  lady  had  three  other  children — all  boys — whose  early  den- 
tition had  presented  no  deviation  from  the  normal  type.  It  is  certainly 
curious  that  the  irregularity  which  had  occurred  in  the  mother  should 
have  been  reproduced  in  the  only  one  of  her  children  whose  sex  was  the 
same  as  her  own.  It  is  important  to  be  aware  that  incompleteness  of  the 
first  crop  of  teeth  does  not  necessarily  imply  that  a  similar  irregularity 
will  be  met  with,  in  the  second.  Mr.  Tomes,  in  his  work  on  dental  surgery, 
refers  to  the  case  of  a  httle  girl  who  cut  none  of  her  milk  teeth,  but  in 
whom  the  permanent  set  appeared  as  usual.  Sometimes,  instead  of  too 
few,  too  many  milk  teeth  are  developed.  A  little  girl  between  two  and 
three  years  old  lately  came  under  my  notice  who  had  five  perfect  incisors 
in  the  lower  jaw. 

The  process  of  dentition  is  much  easier  in  some  children  than  it  is  in 
others  ;  but  it  is  difficult  to  assign  a  reason  for  these  differences.     The  fa- 


558  DISEASE   IN   CHILDEEN. 

cility  with  which  the  teeth  appear  seems  to  be  dependent  more  upon  indi- 
vidual peculiarity  than  upon  actual  bodily  health.  Teeth  cut  early  are  not 
always  cut  easily ;  and  delayed  dentition  is  not  always,  nor  even  usually, 
troul3lesome.  A  perfectly  healthy  child  may  cut  his  teeth  with  much  suf- 
fering, although  fully  up  to  time  ;  while  a  rickety  child,  although  very 
late  in  teething,  may  suffer  no  inconvenience  at  all  in  the  process. 

Symptoms. — The  symptoms  which  accompany  the  eruption  of  the  milk 
teeth  are  very  variable.  Sometimes  no  signs  at  all  are  noticed,  and  noth- 
ing is  known  of  the  matter  until  accident  discovers  the  presence  of  a  tooth 
through  the  gum.  Usually,  however,  the  infant  is  restless  and  u-ritable  ; 
he  flushes  and  is  feverish.  A  copious  secretion  of  sahva  occurs,  and  the 
child  "  dribbles,"  the  fluid  flowing  from  his  lips  over  his  chin.  At  night 
he  is  disturbed  in  his  sleep,  and  in  the  daytime  may  be  noticed  suddenly 
to  give  a  httle  cry,  or  contract  his  features  as  if  in  pain.  He  also  makes  • 
"  munching  "  movements  with  his  jaws,  sucks  his  Hps,  and  gives  everj^  indi- 
cation of  uneasiness  in  his  gums.  Most  writers  on  this  subject,  following 
Hippocrates,  describe  a  painful  itching  sensation  of  the  gum,  which  is  said 
to  be  present  in  these  cases,  and  whether  or  not  the  sensation  is  correctly 
described  as  an  itching,  there  is  no  doubt  that  it  causes  distress,  and  ap- 
pears to  be  reHeved  by  gentle  frictions  vsdth  the  finger  or  any  other  smooth 
object.  On  examining  the  mouth,  the  gum  is  found  to  be  swollen  and 
cushiony,  and  sometimes,  shortly  before  the  tooth  appears,  is  very  tense 
and  hot.  At  this  time,  fi'iction,  which  before  was  pleasant,  becomes  very 
painful.  The  gum  is  evidently  tender,  and  the  child  may  be  sometimes 
seen  to  hold  his  mouth  half  open,  as  if  he  feared  to  close  his  jaws.  All  the 
symptoms  subside  when  the  tooth  pierces  the  gum. 

The  pyrexia  of  teething  is  very  irregular.  It  is  often  higher  in  the 
morning  than  at  night,  and  is  liable  to  rapid  variations.  Thus,  a  little 
boy,  aged  fifteen  months,  had  eight  teeth,  and  was  cutting  his  left  lower 
molar.  At  6  a.m.  his  temperature  (in  the  rectum)  was  99°.  At  10  a.m.  it 
had  risen  to  103.8°  ;  and  at  10  p.m.  was  102.2°.  It  gradually  fell  during 
the  night  (being  taken  every  four  hours),  and  at.  10  a.m.  on  the  following 
morning  was  100°.  It  then  rose  again  to  102°  at  6  p.m.  ;  fell  to  98°  at  2 
a.m.  (third  day),  and  at  10  a.m.  stood  once  more  at  103.8°.  A  good  dose  of 
castor  oil  was  then  given,  and  the  temperature  at  once  became  normal. 

In  a  teething  infant  the  merciu-y  often  registers  104°  at  8  or  9  a.m.  ; 
indeed,  in  a  young  patient  such  an  amount  of  fever  in  the  morning  is  alone 
a  circumstance  of  great  suspicion,  and  should  at  once  lead  us  to  examine 
the  state  of  the  gnims.  Few  diseases,  at  this  early  age,  cause  so  much  pyrexia 
at  this  period  of  the  day. 

The  symptoms  which  have  been  enumerated  do  not  necessarily  herald 
the  immediate  appearance  of  the  tooth,  but  wiU  be  often  found  to  come 
and  go — waxing  and  waning  in  severity,  and  sometimes  subsiding  alto- 
gether, so  that  the  infant  passes  through  alternate  periods  of  suffering  and 
ease  for  some  days,  or  even  weeks,  before  the  tooth  comes  through  the  gum. 
Usually,  more  distress  is  experienced  during  the  eruption  of  the  canine 
teeth  than  at  any  other  period  of  dentition. 

Complications.  — The  symptoms  just  described  may  be  looked  upon  as 
natural  to  the  process  of  teething.  In  many  cases,  other  symptoms  are 
noticed,  expressive  of  derangements  which  do  not  follow  natui-ally  from  the 
evolution  of  the  teeth.  They  arise  as  accidental  troubles,  and  must  be 
attributed  to  the  ordinary  causes  of  ill  health  acting  upon  a  body  in  a  state 
of  irritation  and  fever,  and  therefore  pecuharly  susceptible  to  their  influ- 
ence.    These  are  stomatitis  and  aphtha? ;  repeated  vomiting  or  diarrhoea, 


DERANGEMENTS   OF   TEETHING COMPLICATIONS.  559 

more  or  less  prolonged,  from  catarrh  of  the  stomach  or  bowels ;  cough 
from  pulmonary  catarrh ;  otitis ;  various  forms  of  skin  disease,  and  cer- 
tain troubles  of  the  nervous  system,  such  as  squinting,  convulsions,  etc. 

The  stomatitis  is  of  the  simple  form,  as  a  rule,  and  consists  of  an  erythe- 
matous redness  of  the  mucous  membrane  of  the  gums  over  a  considerable 
area.  The  affected  gums  are  somev^hat  swollen,  and  are  hot  and  tender  to 
the  toiich.  If  the  tenderness  is  great,  the  child  may  refuse  to  suck  the 
bottle  or  its  mother's  breast.  High  fever  always  accompanies  this  comph- 
cation.  The  ulcerative  form  of  stomatitis  is  also  sometimes  present,  and 
has  the  characters  described  in  the  following  chapter. 

Attacks  of  vomiting  and  diarrhoea,  from  acute  gastric  and  intestinal 
catarrh,  are  common  in  teething  children.  For  the  reasons  which  have 
been  stated,  infants,  whether  teething  or  not,  are  at  all  times  Hable  to  ready 
disturbance  of  indigestion  ;  indeed,  at  this  age,  digestive  troubles  form  a 
large  proportion  of  their  ailments.  Therefore,  vomiting  is  especially  apt 
to  occur  when  the  stomach  is  ii-ritable  and  weak  from  j)yrexia,  unless  the 
child's  diet  be  promptly  modified  to  suit  the  altered  state  of  his  digestive 
organs.  In  the  same  way,  whether  from  the  irritation  of  undigested  food, 
or  the  sensitiveness  of  the  heated  body  to  even  trifling  variations  of  the 
external  temperature,  purging  of  a  mild  character  is  a  very  common  symp- 
tom. If  the  teeth  are  cut  in  rapid  succession,  a  looseness  of  the  bowels 
may  prevail  to  a  greater  or  less  degree  during  the  whole  period  ol  denti- 
tion. If  this  looseness  remains  confined  within  moderate  bounds,  it  may 
do  no  apparent  harm  to  the  j)atient ;  but  it  should  not  on  that  account  be 
allowed  to  continue,  for  at  any  time  a  severe  attack  of  inflammatory  diar- 
rhoea may  supervene,  with  not  improbably  fatal  consequences.  This  serious 
accident  is  especially  liable  to  occur  in  hand-fed  babies,  who,  while  they 
are  suffering  from  intestinal  irritation,  are  naturally  more  than  commonly 
sensitive  to  the  disturbing  influence  of  undigested  food.  The  ordinary 
diarrhoea  of  teething  consists  of  green  or  yeUow  matter,  with  small  lumps 
of  curd.  It  is  often  passed  with  straining,  and  its  passage  is  preceded  by 
griping  pains. 

In  cases  of  chronic  diarrhoea,  the  influence  of  teething  is  often  distinctly 
pronounced.  The  irritation  of  the  gum  set  up  by  the  advancing  tooth 
tends  to  maintain  an  irritable  state  of  the  bowels,  so  that,  although  the  act- 
ual purging  may  be  readily  kept  under  control,  an  intolerance  of  milk  and 
the  fermentable  articles  of  food  continues  to  prevail,  and  is  very  difficult  to 
overcome.  Often  in  such  cases,  in  spite  of  the  most  careful  dieting,  attacks 
of  looseness  are  frequent ;  the  child  remains  weak  and  low,  and  seems  to 
make  no  progress  towards  recovery.  When,  however,  the  tooth  appears, 
and  a  pause  occurs  in  the  process  of  dentition,  immediate  improvement  is 
noticed;  the  motions  become  healthy,  and  flesh  and  strength  begin  to  re- 
turn. 

Pulmonary  catarrh,  with  a  hard  cough,  is  a  common  complication  of 
teething  ;  and  the  high  fever  by  which  these  attacks  are  accompanied  may 
cause  great  anxiety,  as  it  gives  a  false  appearance  of  gravity  to  what  is 
really  a  trifling  ailment.  The  child  coughs  a  more  or  less  hard  cough, 
which  may  even  have  a  "  croupy  "  sound  ;  his  nares  dilate  in  inspiration, 
and  the  breathing  is  hurried.  His  mouth  is  hot  and  dry,  and  dribbling, 
if  it  had  been  previously  noticed,  ceases  when  the  fever  begins.  The  child 
is  very  irritable  and  restless  ;  his  tongue  is  furred,  and  his  bowels  are 
confined.  The  catarrh  is  usually  reheved  by  appropriate  remedies  ;  but  if 
care  be  not  taken,  and  the  child  be  exposed  to  cold  or  draught,  a  really  se- 
rere  bronchitis  or  broncho-pneumonia  may  be  induced. 


560  DISEASE  IN   CHILDREI^. 

Otitis  is  a  not  uncommon  accident  at  this  period.  Dr.  "Woakes  has  ex- 
plained the  mechanism  by  which  inflammation  of  the  middle  ear  is  pro- 
duced. Irritation  is  conveyed  from  the  inflamed  gum  to  the  otic  ganghon, 
and  is  then  deflected  to  the  vessel  supplying  the  tympanic  membrane.  As 
a  consequence,  this  membrane  becomes  acutely  congested,  giving  rise  to 
severe  pain  ;  and  if  the  irritation  persist,  it  may  lead  to  inflammation  and 
suppuration  within  the  tympanic  cavity.  The  membrane  soon  becomes 
perforated,  and  a  purulent  discharge  issues  from  the  external  auditory 
meatus  (see  otitis). 

The  forms  of  skin  disease  which  are  hable  to  arise  in  teething  infants 
are  the  erythematous  rashes  and  eczematous  eruptions.  The  former  are 
usually  transient,  and  readily  subside  ;  but  the  latter  may  spread  over  the 
greater  part  of  the  body,  putting  the  child  to  the  greatest  distress  from 
constant  itching,  and  obstinately  resisting  Ireatment. 

Of  the  nervous  disorders  which  are  apt  to  occur  at  this  period  it  is  very 
difficult  to  say  how  far  they  are  due  to  the  actual  jDrocess  of  teething,  or  to 
what  degree  the  rapid  development  of  the  cerebro-spinal  system  is  answer- 
able for  these  accidents.  In  some  impressionable  infants  a  very  tense, 
swollen  gum  may,  I  believe,  like  any  other  variety  of  imitation  in  any  part 
of  the  body,  be  sufficient  to  induce  an  eclamptic  attack.  In  many  cases  the 
convulsion  is  probably  to  be  ascribed  to  otitis,  set  up  by  the  state  of  the 
gum.  Trousseau  has  suggested  that  a  high  degree  of  fever  may  be  in  it- 
self a  sufficient  cause  for  the  nervous  trouble  ;  but  I  have  never  met  with 
a  case  of  convulsions  in  the  child  which  I  could  attribute  to  this  cause  alone  ; 
for  the  initial  convulsion,  which  is  so  common  at  the  beginning  of  many 
acute  diseases  in  early  life,  is  probably  o\%dng  to  other  causes  than  mere 
elevation  of  temperature.  It  is  easy  to  understand  that  an  excitable  infant, 
whose  whole  nervous  system  is  in  a  state  of  disquiet  from  pain,  disturbed 
sleep,  and  continued  dental  irritation,  may  have  convulsions  induced  hj  a 
very  shght  additional  stimulus.  In  such  a  child  a  lump  of  indigestible 
food,  or  a  scybalous  nodule  in  the  bowels,  may  increase  the  u'ritation  to  an 
irresistible  degree,  and  it  is  probable  that  some  such  secondary  cause  often 
has  a  share  in  the  production  of  the  eclamptic  seiziu-e. 

In  the  second  dentition,  the  order  in  which  the  teeth  appear  is  more 
regular  than  in  the  case  of  the  first.  The  eruption  of  the  permanent  teeth 
begins  between  the  ages  of  five  and  a  half  and  seven  years  with  the  ap- 
pearance of  a  permanent  molar  behind  the  last  of  the  temporary  teeth. 
Next  come  the  central  incisors  about  the  eighth  year ;  the  lateral  incisors 
at  about  the  ninth  ;  the  first  and  second  bicuspids  in  the  place  of  the 
temporary  molars  at  the  tenth  and  eleventh;  the  canines  between  the 
twelfth  and  thirteenth,  and  the  second  molars  at  about  the  time  of 
puberty.  The  last  four  permanent  molars  are  cut  later.  The  only  excep- 
tion to  the  above  sequence  that  I  have  noticed  is  that  in  rare  cases  the 
eruption  of  the  central  incisors  precedes  the  appearance  of  the  early  molars. 

In  certain  exceptional  cases  the  milk  teeth  have  been  known  to  be  re- 
tained into  adult  hfe.  Some  years  ago  ]VIi\  Napier  showed  at  a  meeting  of 
the  Koyal  Medical  and  Chirurgical  Society  the  cast  of  the  mouth  of  a  young 
lady  of  twenty-five  in  whom  the  milk  teeth  were  still  retained,  with  the  ex- 
ception of  the  upper  central  incisors.  The  same  abnormality  had  occurred 
in  the  case  of  the  lady's  sister,  and  it  had  been  also  noticed  in  one  of  the 
mother's  relatives. 

The  beginning  of  the  second  dentition  in  dehcate  children  is  often 
accompanied  by  signs  of  gastric  or  intestinal  ii'ritation.  The  child  seems 
very  sensitive  to  changes  of  temperature,  and  is  subject  to  attacks  of  looser 


DERANGEMEISTTS   OF   TEETHING— DIAGNOSIS — TREATMENT.    561 

ness  of  the  bowels.  He  is  often  irritable  and  restless ;  looks  pale,  with 
dark  circles  round  his  eyes,  and  sleeps  badly  at  night.  His  stools  often 
contain  mucus  in  large  quantities.  Such  children  are  very  hable  to  the 
so-caUed  "night  terrors,"  which  in  all  cases,  so  far  as  my  experience  has 
extended,  are  merely  attacks  of  nightmare,  the  consequence  of  indigestion 
and  acidity,  and  can  be  at  once  arrested  by  diet  and  suitable  treatment. 
If,  however,  care  be  not  taken  to  modify  the  child's  diet  to  suit  the  degree 
of  digestive  weakness,  the  derangement  continues  and  the  patient  begins 
to  lose  flesh  ;  indeed,  in  some  cases  a  great  degree  of  emaciation  is 
reached. 

Diagnosis. — The  clinical  importance  of  the  first  dentition  consists  in 
the  frequency  with  which  the  process  is  found  to  complicate  all  the  various 
derangements  and  diseases  to  which  infancy  is  liable.  The  pyrexia  in- 
duced by  teething  often  infuses  an  element  of  obscurity  into  a  case  which 
would  otherwise  present  Httle  difficulty.  In  infants  we  must  be  always 
prepared  for  this  source  of  confusion,  and  should  never  forget  to  ascertain 
the  state  of  the  gums  before  bringing  our  examination  to  a  close. 

In  the  case  of  pulmonary  catarrh  attacking  a  teething  child,  the  com- 
bination of  fever  with  cough,  rapid  breathing  and  active  nares,  suggests 
the  presence  of  pneumonia.  It  will,  however,  be  noticed  that  the  child 
does  not  look  iU  ;  his  cough  is  looser  and  less  hacking  than  the  cough  of 
pneumonia  ;  his  pulse-respiration  ratio  is  not  perverted,  and  the  history 
is  not  that  of  inflammation  of  the  lung.  In  searching  further  for  a  cause 
for  the  pyrexia,  the  gums  will  be  noticed  to  be  tense  and  swollen,  and  the 
source  of  the  fever  is  immediately  explained.  We  must  not,  however,  in 
all  cases  where  the  gums  are  hot  and  uneasy,  at  once  conclude  that  they 
are  the  sole  cause  of  the  symptoms  noticed.  It  sometimes  happens  that 
serious  cerebral  disease  occurs  in  a  teething  child  ;  and  if,  mistaking  their 
nature,  we  attribute  the  nervous  symptoms  to  dental  irritation,  we  make  a 
mistake  which  the  friends  of  the  patient  are  not  likely  readily  to  forget. 
Therefore,  nervous  symptoms  occurring  in  the  course  of  teething  must  in 
every  case  receive  careful  attention.  Headache,  mild  delirium,  vertigo, 
startings,  twitches,  and  convulsive  attacks  are  so  commonly  the  conse- 
quence of  general  nervous  disturbance  from  any  cause,  that  they  have 
lost  aU  claim  to  be  considered  special  manifestations  of  cerebral  disease. 
If,  however,  the  bowels  become  obstinately  confined,  the  pulse  slow  and 
irregular,  the  breathing  unequal  and  sighing  ;  and  if,  in  addition  to  these 
suspicious  symptoms,  we  notice  that  the  child  frequently  frowns  and  avoids 
the  hght ;  that  he  is  sullen  and  drowsy,  hes  with  his  eyes  half  closed,  and 
screams  out  suddenly  as  if  in  pain,  we  have  every  reason  to  fear  the  occur- 
rence of  tubercular  meningitis.  In  all  doubtful  cases  the  effect  of  a  mild, 
aperient  should  be  tried.  Castor  oil  brings  rapid  rehef  in  most  of  the  dis- 
turbances of  a  teething  chUd.  Therefore,  if  the  nervous  symptoms  disappear 
after  the  operation  of  this  simple  remedy,  their  purely  functional  origin  is. 
at  once  apparent. 

In  the  case  of  diarrhoea  from  intestinal  catarrh  occvu-ring  in  a  teething 
child,  there  is  not  the  same  source  of  fallacy  as  in  the  other  comphcations, 
for  in  ordinary  cases  looseness  of  the  bowels  at  once  causes  pyrexia  to- 
subside. 

Treatment. — The  derangements  which  occur  during  dentition  must  be: 
treated  upon  ordinary  principles,  and  the  reader  is  referred  to  the  various; 
chapters  devoted  to  these  derangements  for  information  upon  this  subject. 
It  may,  however,  be  remarked  that  it  is  especially  important  in  a  teething 
child  to  keep  the  belly  warm,  and  to  avoid  all  sources  of  chill.  Also,  that 
36 


562  DISEASE   IN   CHILDKEN. 

it  is  essential,  in  all  cases  where  signs  of  gastric  or  intestinal  disturbance 
are  noticed,  to  reduce  at  once  the  quantity  of  fermentable  food  which  is 
being  taken,  as  fermentation  and  acidity  are  the  earUest  consequences  of 
the  catarrhal  derangement.  In  cases  of  diarrhoea  there  should  be  no  hesi- 
tation about  arresting  the  looseness  as  quickly  as  possible.  A  dose  of 
castor  oil  should  be  given  ;  and  if  the  purging  do  not  cease  after  the  action 
of  the  aperient,  it  wiU  yield  readily  to  bismuth  (gr.  v.-x.)  with  aromatic 
chalk  powder  (gr.  v.),  or  to  one-grain  doses  of  oxide  of  zinc.  If  fever  is 
high,  or  the  gum  seems  to  be  especially  painful,  great  relief  will  follow  an 
aperient  dose  of  castor  oil.  This  at  once  reduces  the  pyrexia  and  calms  the 
tension  and  imeasiness  of  the  gum.  The  irritation  of  the  swollen  and  in- 
flamed gum  may  be  reduced  almost  immediately  by  rubbing  the  afflicted 
part  with  the  finger,  moistened  with  fresh  lemon-juice.  Some  smarting  is 
at  first  excited  by  the  apphcation,  and  the  child's  wailings  are  increased ; 
but  after  a  few  minutes  the  smarting  subsides,  and  with  it  disappears  much 
of  the  discomfort  previously  experienced.  This  practice  is  common,  I 
am  told,  amongst  the  native  nurses  in  the  Cape  Colony. 

The  practice  of  lancing  the  gnim,  which  at  one  time  was  looked  upon  as 
a  sovereign  remedy  for  all  the  disorders  incident  to  the  period  of  teething, 
has  now  but  few  supporters.  The  only  condition  for  which  I  should  feel 
inclined  to  have  recourse  to  it  is  that  in  which  convulsive  attacks  occur  in 
a  child  whose  gums  are  very  tense,  swollen,  and  tender.  In  such  a  case, 
where  it  is  our  object  to  remove  all  sources  of  irritation,  the  gums  may  be 
lanced  freely  with  advantage.  Lancing  the  gums  with  any  view  of  there- 
by hastening  the  evolution  of  the  tooth  below,  is,  of  course,  putting  the  child 
to  very  unnecessary  pain. 

If,  during  the  second  dentition,  signs  of  digestive  disturbance  are  noticed, 
and  the  child  looks  pale  and  begins  to  waste,  and  especially  if  the  symptoms 
called  "night  terrors  "  are  noticed,  the  bowels  should  be  acted  upon  by  a 
mild  aperient  every  three  or  four  days  ;  the  diet  should  be  regulated,  re- 
stricting the  quantity  of  farinaceous  food  and  sweets  (especially  forbidding 
potatoes,  puddings,  cakes,  and  fruit),  and  the  child  may  take  six  or  eight 
grains  of  bicarbonate  of  soda  two  hours  after  each  meal.  I  have  never  seen 
a  case  of  "night  terrors"  which  has  resisted  this  treatment. 


CHAPTER  II. 

STOMATITIS. 

Infants  and  young  children  are  very  liable  to  derangement  of  the  mu- 
cous membrane  lining  the  interior  of  the  mouth.  Partly  on  account  of  the 
irritation  of  the  gums  resulting  from  dentition,  partly  on  account  of  the 
ready  sympathy  which  exists  between  the  membrane  linuig  the  buccal  cav- 
ity and  that  of  the  digestive  apparatus  with  which  it  is  continuous,  an  in- 
flammatory condition  of  the  mouth  is  a  common  disorder.  In  a  healthy 
child  the  lesion  produces  little  more  than  passing  discomfort,  and  readily 
subsides.  In  a  cachectic  or  weakly  subject  the  derangement  may  be  more 
serious,  and  in  some  cases  the  inflammation  passes  into  severe  ulceration 
or  even  gangrene. 

The  simple  form  of  stomatitis,  which  is  often  a  complication  of  teeth- 
ing, has  already  been  described.  In  the  present  chapter  two  other  varie- 
ties of  disease  resulting  from  inflammation  of  the  mucous  membrane  will 
be  considered,  viz. ,  aphthous  or  foUicular  stomatitis,  and  ulcerative  stoma- 
titis. The  following  chapter  will  be  devoted  to  a  serious  and  often  fatal 
disease — gangrene  of  the  mouth,  or  cancrum  oris, 

APHTHOUS  STOMATITIS. 

The  derangement  called  aphthous  stomatitis  (follicular  stomatitis  or 
aphthse)  is  a  common  source  of  inconvenience  to  young  children.  It  is 
induced  almost  invariably  by  derangement  of  the  stomach,  and  is  often 
seen  during  the  progress  of  the  first  dentition — a  time  at  which  so  many 
forms  of  gastric  and  intestinal  disorder  are  apt  to  arise.  Actual  irritation 
of  the  mucous  membrane  of  the  mouth  may  also  give  rise  to  aphthse  ;  for 
children  who  are  over-indulged  with  sweets  often  suffer  from  this  com- 
plaint, even  if  the  digestion  is  unimpaired. 

Symptoms. — -Aphthse  consists  of  a  vesicular  eruption  of  the  mucous 
membrane  of  the  mouth.  Pearly  gray  or  yellowish  vesicles  appear,  vary- 
ing in  size  from  a  pin's  head  to  a  millet-seed.  They  are  circular  or  oval 
in  shape,  and  their  base  is  surrounded  by  a  red  areola.  After  two  or 
three  days  the  vesicle  ruptures  and  a  round  ulcer  remains.  The  base  of 
the  ulcer  is  grayish  in  colour,  from  the  presence  of  a  sebaceous  secretion  ; 
the  edges  are  thickened,  and  there  is  redness  of  the  mucous  membrane 
surrounding  the  sore.  Under  appropriate  treatment  the  ulcer  soon  heals, 
and  the  complaint  is  at  an  end.  The  number  of  the  aphthse  varies  from 
two  or  three  to  fifteen  or  twenty,  or  even  more.  They  may  occupy  any 
part  of  the  mucous  membrane,  but  usually  appear  first  on  the  inner  side 
of  the  lower  lip  and  gums  ;  afterwards  on  the  tip  and  edges  of  the  tongue, 
the  cheeks,  and  on  the  palate. 

Aphthse  are  sometimes  accompanied  by  a  considerable  rise  of  the  tem- 
perature, and  the  thermometer  may  mark  103°  or  104° ;  but  fever  is  not 


564  DISEASE  IN   CHILDREN". 

an  invariable  rule.  The  tongue  is  very  sore,  and  tlie  child,  if  an  infant, 
sucks  with  great  difficulty,  or  may  even  altogether  refuse  the  bottle  or  the 
breast.  He  is  peevish  and  thirsty  ;  often  vomits ;  has  a  sour  smell  from 
the  breath,  and  shows  all  the  signs  of  disordered  stomach.  Often  the 
bowels  are  relaxed. 

If  the  sores  are  so  numerous  as  to  be  almost  confluent,  the  child's  con- 
dition may  cause  some  anxiety.  He  refuses  all  nourishment  on  account  of 
the  smarting  excited  by  the  movements  of  the  tongue  in  the  act  of  swal- 
lowing. His  breath  is  offensive  ;  salivation  is  profuse  ;  the  fontanelle  be- 
comes deeply  depressed,  and  the  sub-maxillary  glands  are  sometimes  en- 
larged. This  severe  form  is  seldom  seen  except  in  weakly  babies,  and  may 
come  on  at  the  end  of  an  attack  of  diarrhoea.  In  these  cases  the  unfavour- 
able termination  of  the  illness  may  be  hastened  by  the  impediment  thus 
created  to  the  taking  of  nourishment.  In  weakly  or  cachectic  children  the 
complaint  is  sometimes  obstinate  ;  for  although  the  course  of  each  indi- 
vidual ulcer  may  not  be  unusually  prolonged,  fresh  vesicles  continually 
appear  as  long  as  the  digestive  derangement  to  which  they  owe  their  origin 
remains  unrelieved.  Again,  in  rare  cases,  the  ulcers  are  slow  to  heal,  and 
may  give  some  trouble  before  they  are  cured. 

Diagnosis. — Aphthae  are  not  difficult  to  recognise.  In  the  vesicular 
stage  the  nature  of  the  derangement  can  scarcely  be  mistaken  ;  and  when 
the  ulcers  have  formed,  their  circular  shape,  uniform  size,  and  the  limita- 
tion of  the  inflammation  to  the  immediate  neighbourhood  of  the  sore,  will 
prevent  the  disorder  being  mistaken  for  the  more  serious  lesion — ulcera- 
tive stomatitis. 

Prognosis. — The  derangement  is  of  little  consequence,  as  a  rule.  Even  in 
the  cachectic  child,  in  whom  the  distribution  of  the  sores  is  more  extended, 
and  their  course  more  obstinate,  than  in  the  healthy  subject,  any  danger 
which  may  be  present  is  due  more  to  the  accompanying  general  condition 
than  to  the  local  complaint.  In  a  healthy  subject,  the  derangement,  under 
judicious  treatment,  will  i-eadily  subside. 

Treatment. — In  ordinary  cases  of  aphthae  all  that  is  required  is  a  dose 
of  rhubarb  and  soda,  with  a  grain  of  gray  powder  to  clear  away  unhealthy 
secretion  from  the  bowels,  and  attention  to  the  cleanHness  of  the  mouth. 
After  each  meal  the  mouth  should  be  washed  out  with  a  piece  of  linen  rag, 
or  a  large  soft  brush,  soaked  in  tepid  water.  Afterwards,  glycerine  and 
borax  (half  a  drachm  to  the  ounce)  may  be  appUed  with  a  soft  camel's  hair 
pencil.  If  an  ulcer  is  slow  to  heal,  it  may  be  touched  gently  with  a  solu- 
tion of  nitrate  of  silver  (ten  grains  to  the  ounce  of  water). 

In  the  more  obstinate  cases,  attention  must  be  paid  to  the  general  con- 
dition of  the  patient,  and  any  chronic  derangement  of  the  alimeiitary  canal 
must  be  remedied.  In  a  cachectic  child,  the  use  of  an  alcoholic  stimulant 
in  sufficient  doses  will  often  cause  a  speedy  improvement  in  the  state  of 
the  mouth. 

ULCERATIVE  STOMATITIS. 

While  follicular  stomatitis  is  more  common  duriag  the  first  eighteen 
months  or  two.  years  of  Hfe,  the  ulcerative  form  of  stomatitis  is  most  fre- 
quently seen  after  the  age  of  two  years,  when  the  first  dentition  has  been 
completed.  The  disease  is  a  common  one  in  hospital  out-patient  rooms, 
and  appears  to  be  predisposed  to  by  insanitary  surroundings,  a  poor  die- 
taiy,  a  weakly  constitution,  or  a  cachectic  state.  On  this  account  it  may  be 
seen  in  children  who  are  overfed  during  convalescence  from  an  acute  ill- 
ness, and  is  an  occasional  consequence  of  a  gastro-intestinal  disorder.     It 


ULCERATIVE   STOMATITIS — SYMPTOMS.  565 

is  said,  also,  sometimes  to  be  epidemic.  Its  immediate  cause  is  often  iin- 
cleanliness  of  the  mouth,  allowing  of  the  accumulation  of  tartar  on  the 
teeth,  and  sometimes  it  is  set  up  by  the  irritation  of  a  decayed  tooth.  In 
rickety  children,  and  those  whose  teeth  decay  rapidly  and  whose  general 
nutrition  is  unsatisfactory,  ulceration  of  the  gums  is  not  an  uncommon 
source  of  discomfort.  The  influence  of  feebleness  of  health,  and  an  in- 
sufficient dietary,  in  producing  the  derangement,  is  so  marked  as  to 
seem  to  justify  Dr.  Cheadle's  suggestion  that  many  cases  of  ulcerative 
stomatitis  occuiTing  in  ill-nourished  children  may  be  due  to  undeveloped 
scurvy. 

In  addition  to  the  causes  which  have  'been  mentioned,  ulcerative  stoma- 
titis may  be  one  of  the  consequences  of  a  special  constitutional  disease. 
Thus,  it  is  sometimes  present  in  cases  of  lymphadenoma,  being  then  due 
to  the  development  of  the  lymphoid  growth  in  the  sub-mucous  tissue. 

Symptoms. — The  ulceration  begins  in  the  gums,  and  is  often  confined  to 
them.  The  gums  at  the  affected  part  become  red,  swollen,  and  spongy- 
looking,  either  generally  or  in  patches.  Their  edges,  especially  where  they 
rise  up  between  the  teeth,  are  soft,  red,  and  unusually  prominent,  and  they 
bleed  very  easily.  The  colour  then  grows  deeper  and  more  purple,  and 
often  at  the  borders  of  the  gum  the  tooth  is  of  a  greenish-yellow  colour. 
There  is  some  pain  in  mastication  ;  sahvation  is  copious,  and  an  offensive 
odour  is  noticed  from  the  mouth.  Soon  a  soft,  pultaceous,  grayish-yellow 
matter  forms  upon  the  inflamed  mucous  membrane.  Tliis  appears  to  arise 
from  gangrenous  softening  of  its  most  superficial  layer,  and  adheres  very 
closely  to  the  tissue  beneath  it.  If  detached,  an  ulcerated  surface  is  dis- 
covered, irregular  in  shape,  grayish  in  colour,  and  bounded  by  a  well-defined 
bright  red  line.  If  treatment  is  not  promptly  resorted  to,  the  disease  usu- 
ally spreads  from  the  gums  to  the  tongue,  the  cheeks,  and  the  lips.  On  the 
tongue  the  lesion  is  usually  Hmited  to  the  part  of  the  organ  in  contact  with 
the  affected  gum  ;  and,  indeed,  in  the  majority  of  cases,  the  ulceration  is 
confined  to  one  side  of  the  mouth,  and  both  cheeks  are  rarely  affected  at 
the  same  time.  The  shape  of  the  ulcerated  surface  varies  according  to  its 
seat.  On  the  lips  it  is  more  or  less  circular  ;  on  the  gums  it  is  elongated, 
and  on  the  interior  of  the  cheek,  from  conjunction  of  several  neighbouring 
ulcers,  it  is  irregular  or  sinuous. 

As  a  consequence  of  the  ulceration  of  the  gums,  the  corresponding  teeth 
often  become  loose,  and  sometimes  fall  out.  Chewing  fs  very  painful,  and 
the  child  is  unwilling,  by  movement  of  his  jaws,  to  increase  his  discomfort. 
Even  the  motions  necessary  for  swallowing  the  copious  saHva  seem  to  be 
painful,  for  a  young  child  allows  it  to  flow  away  from  his  half-open  mouth. 
Like  the  breath,  the  saUvary  secretion  is  horribly  offensive,  and  is  often 
streaked  or  more  or  less  discoloured  with  blood.  If  there  is  disorder  of 
the  stomach,  the  effort  of  retching  may  cause  a  more  copious  haemorrhage 
from  the  inflamed  and  ulcerated  surfaces  ;  and  the  blood,  mixing  with  the 
vomited  matters  during  their  passage  through  the  mouth,  may  appear  to 
come  with  them  from  the  stomach. 

When  the  cheek  becomes  affected  there  is  some  swelling,  but  this  is 
moderate,  and  no  induration  can  be  detected.  The  sub-maxiUary  glands 
are  swollen  and  sometimes  painful.  The  general  health  of  the  child  suf- 
fers much  less  than  might  be  expected.  During  the  first  few  days  the 
temperature  may  rise  to  102°,  or  even  higher  ;  but  the  pyrexia  quickly 
subsides,  and  the  nutrition  of  the  patient  aj)pears  to  undergo  little  change 
unless  diarrhoea  occur.  The  duration  of  the  complaint  is  very  variable. 
If  proper  measures  are  taken,  the  ulceration  is  soon  at  an  end  ;  but  if  left 


566  DISEASE   llS"   CHILDEEN. 

■untreated,  the  lesion  may  persist  for  months,  and  is  said  sometimes  to  pass 
into  cancrum  oris. 

Diagnosis. — The  general  redness  of  the  mucous  membrane  ;  the  pulta- 
ceous  matter  adherent  to  its  surface  ;  the  pecuHar  fcetor  of  the  breath — 
these  symptoms,  together  with  the  large  size,  the  irregular  shape,  and  the 
want  of  rmiformity  of  the  ulcers,  will  serve  to  distinguish  this  complaint 
from  the  preceding.  From  cancrum  oris  it  is  distinguished  by  its  slower 
course,  its  want  of  induration,  and  the  absence  of  black  slough.  The  exu- 
dation cannot  be  confounded  with  the  leathery,  false  membrane  peculiar  to 
the  diphtheritic  inflammation  ;  moreover,  the  latter  disease  is  not  usually 
accompanied  by  ulceration  of  the  mucous  membrane. 

Prognosis. — Ulcerative  stomatitis  is  rather  inconvenient  than  dangerous. 
However  severe  the  affection  may  appear  when  first  seen,  it  is  tractable 
enough  when  judicious  measures  are  adopted  ;  and  the  worst  results  that 
can  follow  are  loss  of  teeth,  with  perhaps  a  superficial  necrosis  of  an  alveo- 
lar process. 

Treatment. — In  every  case  of  ulcerative  stomatitis  our  first  care  should 
be  to  rectify  any  deficiencies  in  the  sanitary  surroundings  of  the  patient, 
or  to  remove  him  at  once  to  a  more  healthy  locality.  Fresh  air  should  be 
especially  insisted  upon,  and  the  child  should  pass  a  large  part  of  his  time 
out  of  doors.  His  diet  should  be  rearranged,  giving  meat,  eggs,  and  milk 
in  suitable  quantities,  especially  avoiding  sweets  and  an  undesirable  excess 
of  farinaceous  food.  Alcohol  is  of  great  value.  The  child  may  take  port 
wine,  diluted  with  an  equal  quantity  of  water,  with  his  dinner,  or  two  or 
three  teaspoonfuls  of  the  brandy-and-egg  mixture  several  times  in  the  day. 

In  addition  to  the  above  measures,  no  time  should  be  lost  in  prescribing 
chlorate  of  potash.  This  remedy  has  an  almost  specific  action  upon  this 
form  of  ulceration.  The  solution,  however,  must  not  be  too  weak.  Three 
grains,  dissolved  in  a  teaspoonful  of  water,  may  be  given  every  four  hours 
to  a  child  of  two  years  old.  For  an  older  child,  the  dose  may  be  increased 
to  five  or  six  grains.  In  some  cases,  larger  quantities  are  foimd  to  be  ne- 
cessary, and  may  be  given  to  quite  j'oung  children  without  apprehension. 
A  case  which  has  resisted  the  remedy  when  given  in  five-grain  doses,  may 
yield  to  it  promptly  when  the  dose  is  raised  to  fifteen.  Of  local  apphca- 
tions,  the  best  is  tepid  water.  Cleanliness  is  of  great  importance,  and 
after  each  meal  the  child,  if  old  enough,  should  be  du-ected  to  wash  his 
mouth  with  warm  water,  so  as  to  prevent  food  from  collecting  about  the 
inflamed  surface.  In  the  case  of  younger  children,  the  mouth  should  be 
swabbed  out  with  a  piece  of  soft  linen  rag  dipped  in  warm  water,  as 
directed  for  aphthae.  Other  applications  which  may  be  used  are  powdered 
alum,  or  a  powder  of  chloride  of  lime.  These  should  be  applied  dry  to  the 
ulcerated  surface  with  the  finger,  and  are  especially  useful  when  the  ulcers 
are  indolent  and  slow  to  heal.  Underwood  speaks  highly  of  the  decoction 
of  cinchona,  made  sharp  with  dilute  sulphuric  acid,  as  an  application  to  the 
sores.  Local  treatment,  however,  with  the  exception  of  careful  cleansing 
of  the  mouth,  is  seldom  required.  Few  cases  will  be  found  to  resist  the 
chlorate  of  potash  treatment,  especially  if  this  be  combined  with  plenty  of 
fresh  air,  and  the  employment  of  an  invigorating  diet  with  a  sufficient 
quantity  of  alcohohc  stimulant.  No  local  treatment  can  be  expected  to 
succeed  if  these  measures  are  neglected. 


CHAPTER  III. 

GANGRENOUS  STOMATITIS. 

Gangrenous  stomatitis  (cancrum  oris,  or  noma)  is  fortunately  much  less 
common  than  the  other  inflammatory  affections  of  the  mouth  and  cheeks. 
The  disease  is  a  very  serious  one,  and  in  the  large  majority  of  cases  proves 
fatal  to  the  child.  Even  when  recovery  happily  occurs,  the  destruction  of 
tissue,  if  at  all  extensive,  leads  to  very  unsightly  contraction  of  the  side  of 
the  face. 

Causation. — Cancrum  oris  is  seldom  seen,  except  in  hospital  practice,  or 
amongst  the  poor.  It  appears  to  be  one  of  the  consequences  of  a  weakly 
habit  of  body,  and  is  most  probably  predisposed  to  by  insanitary  condi- 
tions and  insufficient  food.  The  cases  which  have  come  under  my  notice 
have  been  in  children  at  the  East  end  of  London,  hving  in  miserable, 
squahd  dweUings,  and  very  poorly  clothed  and  fed.  Sometimes  the  gan- 
grene arises  as  a  sequel  of  a  specific  fever  or  serious  inflammatory  dis- 
ease. Thus,  it  has  been  known  to  follow  measles,  typhoid  fever,  scarlatina, 
and  small-pox.  It  may  appear  in  scrofulous  and  tubercular  subjects,  or  in 
children  who  have  been  exhausted  by  a  prolonged  attack  of  broncho- 
pneumonia, or  catarrhal  derangement  of  the  bowels.  It  is  doubtful  whether 
the  injudicious  and  prolonged  use  of  mercury  can  set  up  the  disease.  That 
it  can  do  so,  although  stated  positively,  has  been  denied  with  much  reason. 
In  any  case,  it  is  important  not  to  mistake  the  early  symptoms  of  the  dis- 
ease for  those  of  mercurial  poisoning. 

Ulcerative  stomatitis  is  said,  in  rare  cases,  to  end  in  cancrum  oris.  The 
two  diseases  appear  to  be  induced  by  very  similar  conditions.  A  little  girl, 
aged  five  years,  died  in  the  East  London  Children's  Hospital  from  exten- 
sive gangrene  of  the  right  side  of  the  face.  A  few  days  afterward,  her 
brother,  aged  seven  years,  was  admitted  with  severe  ulcerative  stomatitis, 
inside  the  left  cheek.  The  parents  of  these  children  were  very  poor,  and 
the  patients  themselves  had  been  liaK-starved  and  very  insiifficiently  clad. 
Neither  had  lately  suffered  from  any  acute  disease.  Cancrum  oris  is  rarely 
seen  after  the  sixth  year,  and  girls  are  said  to  be  more  subject  to  it  than 
boys. 

Morbid  Anatomy.— On  post-mortem  examination  of  cases  of  gangrenous 
stomatitis,  the  affected  part  of  the  cheek  or  lip  is  found  to  be  swollen, 
tense,  and  hard  to  the  touch.  It  presents,  at  its  most  prominent  part,  a 
dry,  black,  well-defined  slough.  This  varies  in  size  and  shape,  according 
to  the  extent  to  which  the  mortification  of  the  tissues  has  sjpread.  It  may 
dip  more  or  less  deeply  into  the  substance  of  the  cheek,  and  always  in- 
volves both  surfaces.  The  tissues  in  the  neighbourhood  of  the  slough  are 
thickened,  infiltrated,  and  hardened.  Often  the  dry,  black  eschar  occupies 
the  surface  of  the  cheek  ;  beneath  it,  the  tissues  are  swollen  and  indurated, 
and  in  the  interior  of  the  mouth,  at  the  affected  part,  the  mucous  mem- 
brane is  seen  to  be  occupied  by  a  greyish  ulcerated  surface,  or  a  moist, 


568  DISEASE   IN   CHILDEEN. 

loose  slough,  wliieh  can  be  readily  scraped  away  with  the  handle  of  the 
scalpel. 

The  gums  at  the  seat  of  disease  are  often  sloughy  and  soft ;  the  teeth 
are  loosened,  and  the  alveolar  processes  blackened  and  necrosed.  Some- 
times the  lymphatic  glands  in  the  neighbourhood  are  enlarged. 

According  to  Rilliet  and  Barthez,  the  smaller  blood-vessels  of  the  dis- 
eased cheek  are  obliterated  by  coagulse  where  they  pass  through  the  mor- 
tified tissues.  In  parts  merely  infiltrated  and  swoUen  they  are  still  perme- 
able, although  their  walls  are  thickened.  Batta  Segale  states  that  he  has 
discovered  micrococci  and  bacilli  in  the  detritus  obtained  from  the  gan- 
grenous lesion,  but  it  is  not  clear  that  the  noma  was  dependent  upon  the 
presence  of  these  organisms. 

Other  organs  may  be  the  seat  of  disease.  Broncho-pneumonia  is  very 
common,  and  pysemic  abscesses  have  been  found  in  the  lungs.  Sometimes 
gangrene  of  other  parts  has  been  seen,  especially  of  the  lungs  and  the 
vulva  or  scrotum. 

Symptoms. — In  some  cases  pain  in  one  side  of  the  face  is  the  first 
symptom  complained  of.  The  child  looks  pale  and  ill ;  the  face  begins  to 
swell,  and  at  the  same  time,  or  soon  after,  examination  of  the  cheek  de- 
tects a  firm  spot,  around  which  the  tissues  are  soft  and  oedematous.  At 
this  stage,  inspection  of  the  interior  of  the  mouth  will  discover  a  small 
greyish  ulcer  of  the  mucous  membrane,  corresponding  to  the  hardened 
spot  felt  in  the  substance  of  the  cheek.  The  breath  has  a  gangrenous 
odour,  and  a  dark  bloody  saliva  escapes  from  the  mouth.  There  is  little  or 
no  fever  ;  the  pulse  is  small  and  frequent,  and  the  child  is  unwilling  to 
take  solid  food,  probably  from  the  pain  excited  by  mastication.  Soon  the 
afi'ected  cheek  becomes  tense  and  shining,  the  swelling  increases,  and  a 
small  red  spot  forms  on  the  surface.  At  the  same  time  a  brown  slough 
developes  on  the  mucous  membrane. 

The  ulcer  is  not  always  seated  on  the  cheek.  It  may  occupy  the  gum, 
or  be  placed  at  the  junction  of  the  gum  with  the  cheek.  Wherever  it  first 
appears,  it  soon  spreads,  and  may  involve  the  gum,  the  cheek,  the  lip,  and 
perhaps  the  whole  side  of  the  mouth.  When  the  internal  slough  separates, 
which  it  may  do  on  the  third  or  fourth  day,  it  leaves  a  ragged  ulcer.  At 
the  same  time,  in  severe  cases,  the  red  spot  noted  on  the  outer  surface  of 
the  cheek  becomes  deeper  in  colour,  and  rapidly  changes  into  a  dry,  black 
slough.  Sometimes  the  internal  and  external  sloughs  are  separated  by  in- 
filtrated and  oedematous  tissue  ;  but  often  the  two  sloughs  come  into  con- 
tact, so  as  to  involve  the  whole  depth  of  the  cheek.  In  this  case,  when 
the  slough  separates,  a  ragged  opening  is  left,  of  variable  size.  In  the  in- 
terior of  the  mouth  the  gnims  are  more  or  less  extensively  destroyed  ;  the 
corresponding  teeth  get  loose,  and  often  fall  out,  and  the  maxillary  bone 
may  become  necrosed.  The  separation  of  the  slough  is  often  unattended 
by  hsemorrhage,  but  sometimes  copious  bleeding  takes  place.  The  face, 
on  the  affected  side,  where  it  has  not  been  invaded  by  the  gangrenous  pro- 
cess, is  swollen  and  oedematous,  and  the  infiltrated  eyelids  can  no  longer 
be  opened. 

At  this  stage  the  general  condition  of  the  child  varies.  If  he  have  not 
been  exhausted  by  previous  acute  illness,  although  weak,  he  is  not  pros- 
trated, and  may  be  able  to  sit  up  in  bed  without  assistance.  In  most 
cases,  however,  he  is  excessively  feeble  and  helpless  ;  there  may  be  great 
drowsiness  ;  the  pulse  is  scarcely  perceptible  ;  diarrhoea  may  come  on,  and 
general  oedema  may  occur.  Sometimes  the  appetite  persists,  and  the  child 
takes  Hquid  food  with  avidity  ;  but,  usually,  towards  the  end  he  refuses 


GANGEENOUS  STOMATITIS — SYMPTOMS — TEEATMENT.         569 

food,  and  even  drink.  If  broncho-pneumonia  supervene,  as  often  happens, 
the  temj)erature,  which  had  been  normal,  or  even  below  the  natural  level, 
rises,  and  the  respiration  becomes  hurried  and  laborious. 

In  fatal  cases  the  duration  of  the  illness  varies  according  to  the  rapidity 
with  which  the  gangrenous  process  spreads,  and  to  the  condition  of  the 
child  at  the  time  when  the  disease  begins.  In  very  rapid  cases  the  child 
may  die  in  five  or  six  days.  Usually,  death  takes  place  between  the  tenth 
and  fourteenth  day.  If  the  child  be  in  an  enfeebled  or  cachectic  state  at 
the  time  when  the  first  symptoms  are  noticed,  the  gangrene  usually  spreads 
rapidly,  and  the  end  may  be  reached  before  the  slough  has  had  time  to 
separate.  If  broncho-pneumonia  arise,  or  a  profuse  diarrhoea  be  set  uj),  or 
septicaemia  be  induced,  or  gangrene  appear  in  another  part  of  the  body, 
the  illness  may  end  in  death  rather  abruptly. 

If  recovery  take  place,  it  is  usually  in  cases  where  the  gangrene  rapidly 
limits  itself,  and  does  not  spread  through  the  entire  substance  of  the  cheek. 
The  slough  is  then  thrown  off,  and  a  reparative  process  is  set  up,  which 
ends  in  more  or  less  puckering  of  the  affected  side  of  the  face.  The  fall  of 
the  slough  is,  however,  not  always  followed  by  repair.  In  some  cases  the 
gangrene  continues  at  the  borders  of  the  wound,  and  the  morbid  process 
goes  on  unchecked. 

Diagnosis. — Cancrum  oris  in  its  mildest  form  is  distinguished  from  a 
bad  case  of  ulcerative  stomatitis  by  its  rapid  progress,  the  induration  of  the 
cheek  at  the  base  of  the  ulcer,  and  the  infiltration  of  the  tissues  around. 
Malignant  pustule  presents  symptoms  somewhat  similar  to  those  of  cancrum 
oris,  but  differs  from  it  by  always  beginning  on  the  external  surface  and 
extending  inwards  to  the  mucous  membrane.  In  gangrenous  stomatitis, 
the  mucous  membrane  is  the  first  part  to  be  affected. 

Prognosis. — The  disease  is  fatal  in  the  large  majority  of  cases.  If  it  lead 
to  perforation  of  the  cheek,  especially  if  the  gangrene  be  widely  spread, 
death  is  almost  certain.  I  have  known  one  case  recover  after  perforation  of 
the  cheek ;  but  in  this  instance,  the  gangrenous  process,  although  it  pene- 
trated deeply  into  the  cheek,  had  no  great  lateral  extension.  When  re- 
covery took  place,  a  deep  puckered  cicatrix  was  left  in  the  cheek  at  the  site 
of  the  disease. 

If  a  compHcation  arise,  such  as  broncho-pneumonia  or  diarrhoea,  the 
child's  small  chance  of  recovery  is  still  further  reduced.  As  long  as  he  con- 
tinues to  take  nourishment  well,  and  to  digest  it,  we  may  retain  some  hope 
of  recovery.  If  he  begin  to  refuse  his  food,  or  even  to  receive  it  with  in- 
difference, the  sign  is  a  bad  one. 

Treatment. — As  in  all  diseases  which  result  from  debility  and  malnutri- 
tion, measures  should  be  at  once  adopted  to  improve  the  general  health,  and 
provide  the  child  with  suitable  nourishment  according  to  his  age  and  diges- 
tive capabilities.  Pounded  meat,  strong  beef-tea,  eggs,  and  milk,  should  be 
given  in  small  quantities  at  frequent  intervals,  taking  care  that  the  stomach 
is  not  overloaded,  and  that  the  powers  of  digestion  are  not  overtaxed. 
Stimulants  are  of  great  value.  Port  wine,  or  the  brandy-and-egg  mixture, 
should  be  given  several  times  a  day  with  food.  In  this  disease,  a  child  bears 
stimulants  well.  Half  an  ounce  of  port  wine,  or  two  teaspoonfuls  of  the  qq^ 
flip,  can  be  given  every  two,  three,  or  four  hours,  to  a  child  of  five  or  six 
years  of  age.  The  bowels  must  be  attended  to,  and  if  much  milk  is  being 
taken,  a  teaspoonful  of  compound  liquorice  powder  should  be  administered 
every  other  night.  Fresh  air  is  also  of  great  importance,  and  the  window 
of  the  room  should  be  kept  open  night  and  day.  On  account  of  the  foetor 
of  the  breath,  which  causes  a  most  offensive  odour  in  the  neighbourhood 


570  DISEASE  IIT   CHILDREN. 

of  the  patient,  the  room  must  be  frequently  sprayed  with  a  solution  of  car- 
bolic acid  (one  part  in  thirty  of  water). 

For  local  treatment,  our  first  care  should  be  to  destroy  the  diseased 
surface  in  the  interior  of  the  mouth  with  a  powerful  caustic.  Strong  nitric 
acid  is  usually  employed  for  this  purpose.  The  acid  should  be  apphed  once 
and  effectually.  The  operation  must  be  performed  with  care,  so  as  not  to 
touch  the  teeth,  or  any  part  which  is  not  the  actual  seat  of  disease  ;  and 
immediately  after  the  appUcation  the  mouth  should  be  well  syringed  with 
a  solution  of  carbonate  of  soda  or  chloride  of  lime.  Besides  nitric  acid, 
strong  hydrochloric  acid,  the  acid  nitrate  of  mercury,  nitrate  of  silver,  and 
the  strong  solution  of  perchloride  of  iron  have  been  used,  and  all  have 
their  advocates.  Dr.  J.  Lewis  Smith  speaks  highly  of  a  combination  of  sul- 
phate of  copper  (  3  ij.)  with  pulv.  cinchonse  (  §  ss.),  in  four  ounces  of  water. 
This  application,  which  was  originally  recommended  by  Maunsell  and  Evan- 
son,  is  milder  than  the  others  ;  but  applied  carefully  twice  in  the  day  it  is 
said  to  have  remarkable  efficacy.  If  a  stronger  caustic  is  employed,  a  sec- 
ond apphcation  should  not  be  made  within  twenty-four  hours  of  the  first ; 
indeed,  the  operation  should  only  be  repeated  if  the  further  spread  of  the 
gangrene  is  unmistakable.  The  foetor  of  the  breath  must  be  corrected  by 
frequent  syringing  with  a  disinfecting  agent.  A  solution  of  chlorinated 
soda  (liq.  sodse  chlorinatse  3  j.,  aquae  |  j.)  is  perhaps  the  most  useful ;  or 
one  part  of  carbolic  acid  to  ten  parts  of  water,  as  recommended  by  Labar- 
raque,  may  be  employed  for  the  same  purpose. 

The  internal  administration  of  quinine  and  iron  seems  to  be  beneficial 
in  these  cases,  given  in  full  doses.  A  child  of  three  or  four  years  old  will 
take  well  two  grains  of  quinine  and  twenty  drops  of  perchloride  of  iron, 
with  glycerine  and  water,  every  six  hours.  After  separation  of  the  sloughs, 
any  sign  of  repair  should  be  encouraged  by  stimulating  applications.  A 
weak  solution  of  sulphate  of  zinc  (gr.  iij.  to  the  oz.),  or  any  ordinary  lotion 
for  granulating  wounds,  may  be  used  for  this  purpose. 


CHAPTER  lY. 

THRUSH. 

Thrush  is  a  parasitic  disorder,  and  is  due  to  a  fungus  which  attaches  it- 
self to  the  mucous  membrane  of  the  mouth  and  gullet.  The  complaint  is 
of  importance,  not  so  much  in  itself,  for  when  it  appears  in  a  healthy  child 
the  vegetation  is  readily  dispersed,  as  on  account  of  the  debility  and  seri- 
ous intestinal  and  other  derangements  by  which  it  is  often  accompanied. 
Strictly  speaking,  thrush  is  a  symptom  rather  than  a  disease,  and  often  in- 
dicates a  condition  of  the  system  which  should  give  rise  to  most  serious 
apprehension. 

Causation. — Thrush  is  a  cryptogamic  growth  which  finds  its  nidus  in 
altered  secretion  from  the  mucous  membrane.  It  is  most  common  in  in- 
fants during  the  first  few  weeks  or  months  of  hfe,  and  any  derangement 
which  involves  the  mucous  lining  of  the  mouth  may  tend  to  its  production. 
In  such  subjects,  the  vegetation  is  the  expression  of  a  local  state,  and  this 
local  state  may  itseK  be  the  consequence  of  a  cachectic  condition  or  consti- 
tutional disease.  The  development  of  the  fungnis  is  favoured  by  heat  of 
weather,  want  of  cleanhness,  and  indigestible  food.  It  is  consequently  very 
common  during  the  summer  months  amongst  hand-fed  infants,  especially 
amongst  those  who  are  supplied  with  a  highly  fermentable  diet,  and  are  al- 
lowed to  suck  their  food  from  dirty  bottles.  In  such  cases,  the  passage 
through  the  mouth  of  sour  fluid,  and  the  derangement  of  the  stomach  which 
results  from  fermentation  and  acidity,  maintain  a  state  of  constant  oral  ca- 
tarrh which  forms  a  congenial  medium  for  the  development  of  the  parasite. 
In  a  severe  form  the  complaint  is  never  seen  except  in  imperfectly  nour- 
ished infants,  whose  food  is  ill-selected,  and  whose  general  management 
leaves  much  to  be  desired.  Imperfect  ventilation,  and  general  insanitary 
surroundings,  are  no  doubt  agencies  which  further  the  invasion  of  the  fungus 
and  assist  its  growth.  New-born  infants  crowded  together  in  Foundling 
Hospitals  often  suffer  greatly  from  such  influences,  and  in  these  institu- 
tions thrush  is  a  common  and  much-dreaded  visitor.  Even  after  the  first 
infancy,  the  later  stage  of  many  acute  and  chronic  forms  of  disease  is  hable 
to  be  complicated  by  the  presence  of  the  parasite,  for  in  the  young  child 
a  catarrhal  condition  of  the  alimentary  mucous  membrane  often  forms  a 
necessary  part  of  such  illnesses. 

In  children  suckled  at  the  breast,  the  parasite  is  i^arely  seen  ;  and  if,  on 
account  of  some  temporary  derangement,  it  succeeds  in  establishing  itself 
upon  the  mucous  membrane,  it  is  readily  dislodged  by  suitable  treatment, 
and  quickly  made  to  disappear.  Thrush  does  not  seem  to  be  contagious  in 
the  ordinary  sense  of  the  term.  No  doubt,  if  the  mycelium  be  purposely 
brought  into  contact  with  the  mucous  membrane  of  a  child  who  is  in  a 
favourable  condition  for  its  reception,  the  plant  may  flovuish  in  its  new 
situation  ;  but  in  a  child  whose  mucous  membrane  is  in  a  healthy  state,  the 
experiment  wiU  be  tried  in  vain. 


572  DISEASE  II!f   CHILDEElSr. 

Morbid  Anatomy. — The  parasitic  growth  which  constitutes  thrush,  con- 
sists of  the  mycehum  and  spores  of  a  cryptogamic  vegetation  which  was 
first  described  by  Robin  under  the  name  of  oidium  albicans.  The  fungus 
has  now  been  identified  by  Haller  as  identical  with  the  cidium  lactis  which 
results  from  the  acid  fermentation  of  milk.  The  mucous  membrane  of  the 
mouth  is  first  seen  to  be  red,  and  its  secretion  has  a  distinctly  acid  reac- 
tion. Then,  in  the  course  of  a  few  hours,  little  white  points  appear  upon 
the  reddened  surface,-  especially  on  the  cheeks  and  the  inner  surface  of  the 
lij)s.  These  increase  in  number  and  in  size,  and  by  the  second  day  are 
seen  to  have  united  into  patches  which  cover  a  considerable  extent  of  sur- 
face. Even  before  the  ajopearance  of  the  white  points,  a  gentle  scraping  of 
the  mucous  membrane  reveals  to  the  microscope  many  spores  of  the  fun- 
gus. These  are  elongated  cells — egg-shaped  bodies — which  are  often  at- 
tached to  one  another  by  their  ends,  so  as  to  form  groups  of  two,  three,  or 
four.  The  white  points  are  found,  on  examination,  to  consist  of  these  con- 
nected spores,  combined  with  scaly  epithelium  from  the  mucous  membrane, 
detached  spores  and  molecular  deposit. 

The  white,  newly-formed  membrane  coats  the  interior  of  the  mouth  and 
gullet ;  but  is  usually  confined  to  parts  covered  with  scaly  epithelium,  for 
it  avoids  the  nasal  passages,  and  seldom  penetrates  into  the  larynx.  Par- 
rot, however,  states  that  he  has  seen  evidence  of  its  presence  on  the  vocal 
cords.  The  advance  of  the  membrane  down  the  alimentary  canal  was  for 
a  long  time  supposed  to  be  arrested  at  the  cardiac  end  of  the  stomach  ;  but 
Parrot  asserts  that  the  fungus  is  occasionally  to  be  discovered  in  the  stom- 
ach and  bowels.  In  these  situations  it  presents  a  peculiar  appearance. 
In  the  stomach  it  is  seen  as  small  granules,  separate  or  grouped,  and  vary- 
ing in  size  from  a  millet-seed  to  a  particle  invisible  to  the  naked  eye.  The 
smaller  are  pointed  ;  the  larger  are  slightly  depressed  in  the  middle.  In 
colour,  they  differ  little  from  the  mucous  membrane  on  which  they  are 
placed,  but  some  have  a  faint  yellow  tint.  They  adhere  firmly  to  the  sur- 
face, and  cannot  be  scraped  off  or  washed  away.  The  thrush  granules  affect 
principally  the  posterior  surface,  esjoecially  the  neighbourhood  of  the  pos- 
terior curvature,  and  lie  nearer  to  the  cardia  than  to  the  pylorus.  Sur- 
rounding them,  the  mucous  membrane  retains  its  colour,  or  is  of  a  rose  or 
violet  tint.  Parrot  examined  sections  of  the  gastric  mucous  membrane, 
and  found  the  more  superficial  portions  of  the  glands  to  be  destroyed  by 
the  parasitic  vegetation,  which  had  penetrated  into  their  interior,  and  had 
also  advanced,  althoiigh  to  a  less  extent,  into  the  intervening  tissue.  Ac- 
cording to  Wagner,  the  spores  and  filaments  can  be  sometimes  detected 
within  the  blood-vessels  of  the  part. 

In  the  intestines.  Parrot  states  that  he  has  succeeded  in  discovering  the 
fungus  only  in  rare  cases.  In  each  instance  its  seat  was  the  caecum. 
Whether  the  growth  has  the  power  of  attaching  itself  to  the  anus,  is  not 
clear,  for  an  examination  of  the  whitish  pultaceous  matter  sometimes  found 
at  the  orifice  of  the  rectum,  revealed  merely  pavement  epithehum  in  strati- 
fied layers,  with  some  doubtful  cells  which  presented  a  certain  analogy  with 
the  filaments  of  thrush.  On  the  mucous  membrane  of  the  mouth,  the 
thrush  membrane  is  at  first  white,  and  firmly  adherent.  After  a  few  days 
its  colour  becomes  browner,  and  its  connection  with  the  mucous  surface 
less  intimate,  so  that  it  can  be  readily  wiped  away  with  a  brush  or  piece  of 
wet  rag. 

In  all  cases  of  death  from  the  serious  intestinal  derangement  or  the  con- 
stitutional cachexia  of  which  thrush  is  a  chief  local  expression,  extreme 
atrophy  of  the  tissues  is  a  striking  phenomenon.     The  infants  are  usually 


THEUSH — MORBID    AISTATOMY — SYMPTOMS.  573 

in  a  state  of  profound  malnutrition,  and  present,  according  to  Parrot, 
fatty  degeneration  of  the  kidneys,  the  lungs,  and  the  brain,  sometimes  tJ- 
ceration  of  the  stomach,  and,  not  unfrequently,  haemorrhages  within  the 
cranial  cavity. 

Symptoms. — In  cases  where  the  parasitic  growth  attaches  itself  to  the 
mucous  membrane  of  a  sturdy  infant,  the  appearance  of  the  white  points 
is  preceded  by  redness  and  soreness  of  the  mouth,  and  a  rise  of  temperature. 
The  child  is  noticed  to  suck  with  difficiilty,  and,  if  hand-fed,  may  refuse  the 
bottle.  He  seldom,  however,  declines  the  breast  for  this  reason.  Often 
he  makes  movements  with  his  lips,  cries  if  a  finger  is  introduced  into  his 
mouth,  and  is  evidently  uneasy.  His  temperature  often  rises  at  night  to 
103°  or  104°.  At  the  same  time  there  may  be  a  little  looseness  of  the 
bowels,  j^receded  by  coHcky  pains.  The  motions  are  slimy  or  green,  but  not 
very  offensive.  Often  they  are  acrid,  and  cause  some  redness  and  excoria- 
tion of  the  nates.  This  is  looked  ujoon  by  nurses  as  a  satisfactory  symptom, 
being  considered  to  indicate  that  the  thrush  "  has  gone  through  "  the  child. 
In  many  cases  there  is  derangement  of  the  stomach,  and  vomiting. 

The  above  constitutes  the  whole  of  the  symptoms.  Although  the  tem- 
perature is  raised,  the  stools  have  an  innocent  appearance,  and  the  face  ex- 
presses no  distress.  In  the  mouth,  the  thrush  is  limited  to  a  few  white 
patches,  looking  like  particles  of  curd  adhering  to  the  mucous  membrane. 
They  are  seen  on  the  inner  side  of  the  cheeks  and  lips,  on  the  tongue,  some- 
times on  the  hard  jpalate,  but  seldom,  in  these  cases,  at  the  back  of  the 
throat.  They  may  be  removed  with  a  Httle  trouble,  and  leave  the  mucous 
surface  on  which  they  had  been  seated  raw-looking. and  bright  red.  When 
thus  removed,  similar  little  patches  quickly  appear  in  their  j)lace,  but  after 
a  few  days  the  surface  cleans,  and  the  child  is  well. 

This  simple  variety  is  the  shape  the  complaint  assumes  in  ordinary  cases, 
and  practitioners  whose  experience  is  collected  entirely  from  families  in 
easy  circumstances  may  have  observed  it  in  no  other  form.  In  hospitals 
and  asylums  where  infants  are  admitted  it  is  seen  as  a  much  more  serious 
complaint.  In  babies  who  have  been  neglected  or  fed  injudiciously,  and 
confined  to  dirt}',  ill-ventilated,  foul-smeUing  rooms — poor,  miserable  Httle 
objects,  who  have  sunk  from  these  causes  and  the  consequent  bowel  derange- 
ment into  a  state  of  extreme  atrophy  and  weakness,  the  whole  of  the  interior 
of  the  mouth  and  fauces  is  often  completely  lined  by  the  white  thrush  mem- 
brane. The  layer  adheres  closely  to  the  mucous  membrane,  and  can  only 
be  detached  with  great  difficulty.  If  this  be  done,  the  mucous  surface 
beneath  is  seen  to  be  raw,  and  sometimes  ulcerated.  According  to  Valleix, 
shallow  ulcers  on  the  hard  jDalate  may  precede  the  appearance  of  the  para- 
sitic vegetation.  An  infant  so  affected  cannot  suck,  and,  indeed,  often  can 
hardly  swallow..  His  mouth  is  dry  ;  his  hps  are  red  and  dry-looking,  and 
at  the  surfaces  where  they  come  into  contact,  white  scattered  particles  of 
thrush  can  be  perceived,  even  when  the  lips  are  almost  closed.  The  child's 
eyes  and  cheeks  are  sunken  ;  his  face  is  pale  and  haggard,  and  marked  with 
a  weU-defined  nasal  line  which  becomes  a  deep  furrow  on  any  movement  of 
the  lips.  The  buttocks  and  genitals  are  often  covered  with  an  erythematous 
or  eczematous  redness,  and  ulcerations  may  be  noticed  on  the  internal  mal- 
leoH,  and  sometimes  also  on  other  bony  projections.  His  skin  is  loose  and 
is  excessively  inelastic,  often  lying  in  lax  folds  upon  the  belly.  The  child 
whimpers  feebly,  but  never  cries.  His  mouth  has  a  soui',  or  even  a  cadaver- 
ous smell.  The  motions,  more  or  less  profuse,  are  equally  offensive.  He 
gets  weaker  and  weaker,  and  gradually  sinks  out  of  life.  Sometimes  the  con- 
dition known  as  "  spurious  hydrocephalus  "  is  noticed  before  death.     The 


674  DISEASE  IN   CHILDEElSr. 

temperature  varies.  Sometinies,  on  tlie  first  appearance  of  tlie  parasite,  the 
internal  temperature  is  found  to  be  101°,  or  higher,  although  the  extremi- 
ties feel  cold  ;  but  after  a  time  the  temperature  falls  below  the  level  of 
health,  and  may  be  only  96°  or  97°  in  the  rectum.  In  many  of  these  cases, 
the  secretion  of  urine  is  diminished.  According  to  Parrot,  it  often  contains 
albumen  ;  and  this  pathologist  is  disposed  to  attribute  the"  cerebral  phe- 
nomena which  are  apt  to  occur  in  these  cases  to  toxic  causes,  from  retention 
in  the  blood  of  urinary  elements. 

In  these  severe  cases  the  general  symptoms  depend  upon  the  intestinal 
catari'h,  or  other  primary  lesion,  whatever  it  may  be,  which  has  reduced  the 
infant's  strength,  and  prepared  the  way  for  the  invasion  of  the  parasite. 
Often  the  illness  ends  in  a  profuse  diarrhoea,  but  the  bowels  are  not  invariably 
relaxed.  In  some  cases,  an  attack  of  catarrhal  pneumonia,  or  pulmonary 
catarrh,  with  collapse  of  the  lung,  may  bring  the  Hfe  of  the  infant  pre- 
maturely to  a  close. 

Diagnosis. — Thrush  is  not  difficult  to  detect.  We  have  merely  to  ex- 
amine the  mouth  of  the  infant,  and  observe  the  white  adherent  patches 
sj)rinkled  over  the  surface  of  the  mucous  membrane.  If  a  particle  of  one 
of  these  patches  be  detached  and  placed  under  the  microscope,  the  charac- 
teristic spores  and  filaments  will  at  once  be  noticed. 

It  is  possible  that,  in  the  rare  cases  where  diphtheritic  false  membrane 
is  seen  on  the  interior  of  the  hps  and  mouth,  it  may  be  mistaken  for  thrush, 
but  diphtheritic  membrane  is  thicker,  tougher,  and  more  leathery  in  text- 
ure, less  white  in  colour,  and  under  the  microscope  shows  no  spores. 
Moreover,  the  superficial  cervical  glands  are  enlarged  and  tender  in  diph- 
theria.    In  cases  of  thrush  they  are  not  affected. 

Particles  of  ciu'd  clinging  to  the  gums  and  cheeks  of  a  child  who  has 
just  taken  his  bottle  have  exactly  the  appearance  of  disseminated  particles 
of  thrush  ;  but  they  can  be  readily  wiped  off  with  a  small  brush  or  feather, 
and  on  their  disappearance  leave  no  redness  of  the  mucous  membrane. 

Prognosis. — In  cases  of  thrush,  the  probabilities  of  the  child's  recovery 
depend  partly  upon  his  general  condition,  partly  upon  the  extent  of  surface 
covered  by  the  vegetation.  If  thrush  appear  in  the  mouth  of  a  sturdy, 
weU-nourished  chUd,  as  a  consequence  of  some  temporary  derangement, 
the  symptom  is  one  of  little  consequence,  and  the  parasite  can  be  readily 
dispersed.  In  a  child,  enfeebled  and  wasted  by  chronic  digestive  de- 
rangement, or  the  victim  of  inherited  syphihs,  the  aj)pearance  of  thrush  in 
the  mouth  is  a  symptom  of  the  utmost  gravity.  In  such  a  case,  the  child's 
only  chance  of  recovery  depends  upon  the  rapid  introduction  of  nourish- 
ment into  his  system,  but  a  deranged  condition  of  the  mucous  membrane 
may  neutralize  aU  our  efforts  to  improve  the  state  of  his  nutrition.  In  an 
infant  so  reduced,  the  rapidity  vrith  which  the  fungus  is  seen  to  spread 
over  the  surface,  may  be  taken  as  a  measure  of  the  severity  of  the  digestive 
derangement.  If  it  rapidly  cover  the  whole  interior  of  the  mouth  and 
throat,  the  child's  chances  of  recover)^  in  his  weakly  state  are  smaU  indeed. 

Treatment. — In  mild  cases  of  thrush,  our  first  care  should  be  to  remedy 
the  temporary  gastric  derangement  which  has  allowed  the  parasitic  growth 
to  effect  a  lodgment  on  the  mucous  membrane.  The  diet  must  be  modified 
as  recommended  in  the  chapter  on  infantile  atrophy  ;  and  if  the  bowels 
are  relaxed,  the  looseness  must  be  arrested  by  suitable  treatment  (see 
page  626).  If  not  relaxed,  they  should  be  acted  on  by  a  dose  of  rhubarb, 
with  a  grain  of  gi'ay  powder.  Afterwards,  a  draught  containing  a  few 
grains  of  carbonate  of  soda,  with  an  aromatic,  should  be  given  three  or 
four  times  a  day.   If  there  is  nausea,  the  stomach  should  be  cleared  out  by 


THRUSH — TREATMENT.  ,  575 

an  emetic  of  sulphate  of  copper  (half  a  grain  in  a  teaspoonful  of  water),  or 
a  teaspoonful  of  ipecacuanha  wine,  given  every  ten  minutes  until  vomiting 
is  produced. 

Fresh  air  is  of  extreme  importance.  If  the  weather  is  suitable,  the 
child  should  pass  much  of  the  day  out  of  doors  ;  and  especial  care  should 
be  taken  that  his  sleeping-chamber  is  sufficiently  ventilated,  and  that 
soiled  linen  is  not  allowed  to  remain  in  the  room  to  vitiate  the  air. 

With  regard  to  local  treatment : — Perfect  cleanliness  is  indispensable. 
Directly  the  infant  has  taken  the  bottle,  his  mouth  should  be  swabbed  out 
with  a  piece  of  soft  linen  rag,  or  a  large  camel's-hair  brush,  moistened  with 
warm  water.  Afterwards,  the  whole  of  the  interior  of  the  mouth  should 
be  brushed  over  with  a  solution  of  borax  (half  a  drachm  to  the  ounce)  in 
water  sweetened  with  glycerine.  If  this  treatment  be  repeated  after  each 
meal,  it  will  not  be  long  before  all  signs  of  the  fungus  have  disappeared. 

In  the  more  sevei'e  examples  of  the  complaint  the  same  local  treatment 
must  be  employed.  If  the  fungus  be  suspected  to  have  passed  into  the 
gullet,  the  child  may  be  forced  to  swallow  a  few  drojDS  of  the  wash  diluted 
with  water.  If  superficial  ulceration  are  seen,  ten  grains  of  sulphate  of 
zinc  may  be  added  to  each  ounce  of  the  wash,  for  use  as  an  application  to 
the  mucous  membrane.  The  chief  difficulty  in  these  cases  is  to  improve 
the  child's  nutrition  and  increase  his  strength.  If  the  parents  are  in  a 
position  to  supply  a  wet  nurse,  this  method  of  feeding  should  be  adopted 
at  once.  If  the  child  is  forced  to  trust  to  the  bottle,  ass'  milk  or  the  milk 
of  the  goat  is  preferable  to  that  of  the  cow.  Either  should  be  given 
pancreatised  according  to  the  method  recommended  elsewhere  (see  page 
606).  White  wine  whey  is  a  valuable  resource  in  these  cases,  and  if  the 
infant  be  much  reduced  in  flesh  and  strength,  with  small  digestive  power, 
he  may  subsist  upon  it  entirely  for  the  first  few  days.  A  dessert-spoonful 
of  fresh  cream  shaken  up  with  each  bottleful  of  the  whey  makes  it  more 
nutritious,  and  is  a  very  digestible  addition  to  the  meal.  In  all  cases,  the 
internal  treatment  will  depend  upon  the  accompanying  conditions,  and  es- 
pecially upon  the  nature  of  the  illness  in  the  course  of  which  the  local  com- 
plaint has  appeared.  Often  the  child  is  the  subject  of  a  chronic  intestinal 
catarrh.  This  must  be  treated  as  directed  elsewhere  (see  page  640).  If 
the  purging  is  moderate,  and  there  is  no  reason  to  suspect  the  presence  of 
ulceration  of  the  bowels,  much  benefit  may  be  often  derived  from  a  powder 
containing  one  grain  of  rhubarb,  mth  one  grain  of  powdered  bark,  and 
three  grains  of  aromatic  chalk,  given  two  or  three  times  in  the  day. 

Fresh  air,  with  warmth  to  the  belly,  and  the  most  perfect  cleanliness, 
not  only  of  the  child's  body  and  linen,  but  also  of  all  spoons,  cups,  feeding- 
bottles,  etc.,  used  in  his  nursery,  are  essential  to  his  recovery. 


CHAPTER  Y. 

PHARYNGITIS. 

Phaeyngitis,  or  sore  throat,  is  common  at  all  ages,  and  is  a  frequent  com- 
plaint in  early  life.  The  disorder  may  be  met  with  as  a  simple  catarrh  of 
mucous  membrane  ;  as  an  inflammation  affecting  especially  the  mucous 
follicles  ;  as  an  eruption  of  herpes  in  the  pharynx,  or  as  part  of  a  severe 
constitutional  disease.  Four  varieties  will  then  be  considered,  viz.,  simple 
catarrhal  pharyngitis  ;  follicular  pharyngitis  ;  herpetic  pharyngitis,  and  tu- 
bercular pharyngitis. 

SIMPLE  CATARRHAL  PHARYNGITIS. 

Causation. — Catarrh  of  the  pharynx,  like  catarrh  attacking  other  parts 
of  the  body,  is  usually  the  consequence  of  a  chill.  Any  cause  which  in- 
cHnes  the  body  to  be  affected  by  changes  of  temperature  will  help  to  induce 
the  disorder.  It  is,  therefore,  common  in  scrofulous  subjects,  in  children 
enfeebled  by  confinement  to  heated,  ill-ventilated  rooms,  and  in  those  resi- 
dent in  houses  where  the  air  is  contaminated  by  an  imperfect  system  of 
drainage.  Direct  irritants  to  the  throat  will  also  set  up  pharjmgitis,  which 
at  once  passes  beyond  the  limits  of  an  ordinary  pharyngeal  catarrh.  The 
children  of  the  poor  are  often  brought  to  the  hospital  with  severe  scalds  of 
the  throat  from  attempting  to  drink  boiling  water  out  of  the  spout  of  a 
kettle.  In  the  above  cases  the  disorder  is  a  primary  lesion.  It  may,  how- 
ever, occur  secondarily  to  some  general  disease.  Thus,  catarrh  of  the 
pharynx  is  an  invariable  consequence  of  measles  and  scarlatina.  It  is  also 
common  in  typhoid  fever,  in  rheumatism,  and  in  erysipelas.  In  all  cases, 
the  derangement  is  an  acute  process,  although,  if  frequently  repeated,  it 
tends  to  set  up  a  relaxed  and  congested  state  of  mucous  membrane. 

Symptoms. — In  mild  cases,  the  first  symptom  is  usually  a  sore  feeling  in 
the  throat,  which  is  increased  by  swallowing.  On  examination  of  the 
throat  the  back  of  the  fauces,  the  soft  palate,  and  the  tonsils  are  noticed-  to 
be  red,  and  the  latter  may  be  slightly  swoUen.  The  tongue  is  ftu'red,  and 
the  child  is  thirsty.  In  scrofulous  suljjectsthe  temperature  almost  invaria- 
bly rises,  and  there  is  a  certain  amount  of  pallor  and  languor.  In  the 
slighter  forms  little  more  is  to  be  discovered.  After  a  day  or  two  the  child 
begins  to  snuffle,  and  the  throat  affection  disappears  as  a  nasal  catarrh  be- 
comes established. 

In  the  severe  variety  the  earHer  symptoms  are  more  pronormced.  The 
child  feels  iU  and  looks  tired.  His  face  is  pale,  his  eyelids  are  dark,  he 
complains  of  weariness  and  aching  in  the  limbs,  and  asks  to  go  to  bed. 
Often  he  sits  over  the  fire  and  says  he  is  cold.  In  a  few  hours  soreness  of 
the  throat  begins.  The  fauces  are  found  to  be  red  and  the  tonsils  to  be 
slightly  swollen.  Whitish  pultaceous  matter  may  be  seen  at  the  openings 
of  the  crypts  of  the  tonsils,  and  sometimes  at  the  back  of  the  pharynx.     In 


CATAERHAL    PHARYNGITIS — SYMPTOMS — TEEATMEISTT.       577 

scrofiilous  subjects  the  temperature  generally  rises  to  104°  or  105°,  and  in 
such  children  the  glands  of  the  neck,  although  Httle  enlarged,  are  tender 
when  the  neck  is  pressed.  The  tongue  is  thickly  furred,  and  in  most  cases 
the  nasal  passages  and  the  gastric  mucous  membrane  are  also  the  seat  of 
catarrh.  Moreover,  the  eyes  look  red  and  watery,  and  the  child  avoids  the 
hght.  In  a  day  or  two  the  catarrh  often  spreads  to  the  Eustachian  tubes, 
so  that  there  is  some  deafness.  The  voice  is  nasal,  and  swallowing  causes 
great  pain,  so  that  the  child  refuses  all  solid  food.  The  bowels  are  usually 
confined  ;  but  if  there  is  any  intestinal  catarrh,  the  disorder  may  be  accom- 
panied by  purging. 

After  twenty-four,  or,  at  the  latest,  forty-eight  ho-urs,  the  fever  consider- 
ably diminishes,  but  the  temperature  may  remain  at  100°  or  101°  for  a  day 
or  two  longer.  Usually,  after  the  third  or  fourth  day  the  symptoms  begin 
to  subside,  and  by  the  end  of  the  week  the  child  is  convalescent.  If  the 
patient  has  suffered  many  times  previously,  the  deafness  may  not  subside 
with  the  other  symptoms,  but  may  persist  for  a  week  or  so  longer. 

A  scald  in  the  throat  is  accompanied  by  great  nervous  prostration. 
There  is  severe  pain  in  swallowing,  and  consequently  an  almost  entire  ina- 
bihty  to  take  food.  The  mucous  membrane  of  the  mouth,  palate,  and 
pharynx,  looks  whitish  ;  raw  patches  are  seen,  from  which  the  mucous  mem- 
brane has  been  removed,  and  there  is  much  swelling.  Often  the  larynx 
is  also  injured,  so  that  acute  laryngitis  is  set  up,  and  oedema  of  the  glottis 
may  be  induced. 

Diagnosis. — An  ordinary  pharyngitis  can  usually  be  readily  recognised. 
The  chief  difficulty  is  to  exclude  diseases  of  which  pharyngitis  is  a  promi- 
nent symptom,  especially  scarlatina  and  measles. 

In  scarlatina,  the  pharynx  visually  presents  a  peculiar  appearance.  The 
redness  is  of  a  very  bright  colour,  and  is  diffused  over  the  whole  of  the 
fauces.  Often  it  is  punctiform  on  the  soft  palate,  or,  even  if  the  redness 
here  is  uniform,  the  punctate  appearance  can  be  detected  at  the  edges  of 
the  redness.  Moreover,  in  scarlatina,  the  feeling  of  soreness  begins  quite 
suddenly,  as  a  rule,  and  the  attack  is  accompanied  by  vomiting  and  a  very 
rapid  pulse.  In  twenty-four  hom's  the  characteristic  eruption  is  to  be  dis- 
covered. 

If  the  signs  of  catarrh  are  general,  and  the  sore  throat  is  accompanied 
by  slight  ophthalmia  and  running  from  the  nose,  measles  may  be  suspected. 
Indeed,  the  invasion  of  the  eruptive  fever  is  accompanied  by  symptoms 
which  cannot  be  distinguished  from  those  of  an  ordinary  catarrh.  If,  on 
the  third  day,  the  fever  is  as  high,  or  higher,  than  on  the  first,  the  continu- 
ance of  the  pyrexia  tells  in  favoui-  of  the  exanthem  ;  but  no  positive  opin- 
ion should  be  hazarded  until  after  the  fom-th  day,  when,  if  the  case  be  one 
of  measles,  the  characteristic  rash  may  be  expected  to  appear. 

Treatment. — It  is  not  often  that  medical  advice  is  sought  in  a  case  of 
ordinary  catarrh,  the  derangement  being  one  which  is  considered  espe- 
cially suitable. for  domestic  medication.  If,  however,  the  fever  is  high,  the 
medical  practitioner  may  be  called  in.  A  feverish  child  should  be  con- 
fined to  his  bed.  He  should  take  a  grain  of  calomel,  followed  by  a  sahne 
aperient,  and  his  diet  should  consist  of  milk,  broth,  and  dry  toast.  A  cold 
compress,  or  a  layer  of  cotton  wool,  may  be  applied  to  the  throat.  If  the 
case  be  seen  early,  it  is  useful  to  prescribe  the  hypophosphite  of  lime,  which 
has  a  reaUy  remarkable  influence  in  cutting  short  an  ordinary  catarrh. 
For  a  child  five  years  of  age,  three  grains  of  the  salt  may  be  given  with  five 
drops  of  spirits  of  chloroform  and  ten  of  tincture  of  cardamoms,  in  two 
teaspoonfuls  of  water,  thi-ee  times  a  day.  A  mild  catarrh  is  often  arrested  at 
37 


578  DISEASE  iisr  childeen. 

once  by  this  means,  and  even  in  severe  cases  the  course  of  the  derangement 
is  sensibly  shortened  by  the  remedy.  The  pyrexia  usually  subsides  quicjdy 
after  the  action  of  the  aperient.  If  it  persist,  a  drop  or  two  of  tincture  of 
aconite  may  be  given  in  a  teaspoonfvil  of  water  every  two  or  three  hours. 

If  the  throat  remain  relaxed  after  the  subsidence  of  the  pyrexia,  a  mild 
astringent  gargle,  if  the  child  can  use  it,  or  a  rhatany  or  tannin  lozenge 
sucked  two  or  three  times  a  day,  will  produce  a  bracing  effect.  In  cases 
where  there  remains  a  great  sensitiveness  to  chills,  the  susceptibility  may 
be  considerably  diminished  by  the  daily  use  of  a  cold  douche,  administered 
in  the  manner  elsewhere  recommended  (see  page  17). 

Severe  scalds  of  the  thi'oat  usually  occur  in  the  younger  children.  If 
the  pain  be  severe,  it  may  be  allayed  to  some  extent  by  sucking  ice,  or 
by  administering,  occasionally,  a  teaspoonful  of  cmshed  ice  on  which  a  little 
sugar  has  been  sprinkled.  Small  doses  of  opium  are  often  necessary  ; 
and  this  remedy  applied  locally,  as  by  sprajdng  the  throat  mth  glycerine 
and  water,  made  anodyne  with  a  few  drops  of  laudanum,  is  very  beneficial. 
If  the  child  cannot  swaUow,  he  may  be  fed  through  a  stomach-tube  passed 
through  the  nose,  as  directed  in  a  previous  chapter  (see  page  15).  Rectal 
alimentation  is  very  imsatisfactory  in  young  subjects. 

If  laiyngitis  occur,  it  must  be  treated  as  described  elsewhere  (see 
page  410). 

FOLLICULAR  PHARYNGITIS. 

Chronic  inflammation  of  the  folhcles  of  the  pharynx  is  an  obstinate  com- 
plaint which  is  often  seen  in  children.  The  disorder  is  an  important  one, 
as  it  may  induce  deafness,  and  frequently  gives  rise  to  a  persistent  cough, 
which  is  a  cause  of  much  anxiety  to  the  patient's  relatives. 

Causation. — FoUicular  pharyngitis  is  especially  likely  to  attack  strumous 
subjects,  and  those  who  belong  to  famihes  in  which  there  is  a  gouty  or 
rheumatic  tendency.  The  disorder  is  not  often  seen  in  very  young  chil- 
dren, although  Dr.  Morell  Mackenzie  has  met  with  it  as  early  as  the  third 
year.  It  is  most  commonly  found  in  children  of  eleven  or  twelve  years  of 
age  and  upwards.  It  sometimes  appears  to  follow  certain  specific  fevers, 
such  as  measles,  scarlatina,  and  smaU-pox.  In  other  cases  it  is  apparently 
excited  by  exposure  to  cold  acting  upon  a  weakly  fi'ame.  The  subjects  of 
the  disorder  are  often  ill-nourished  and  feeble-looking  ;  and  this  fact, 
coupled  with  the  cough  which  is  so  common  a  consequence  of  the  disease, 
may  give  rise  to  fears  of  consumption. 

Morbid  Anatomy. — The  follicles  are  enlarged  and  their  walls  thickened. 
They  are  filled  with  a  cheesy  secretion  consisting  of  degenerated  epithelial 
cells,  molecules,  and  oil-globules  ;  and  sometimes  contain  concretions  ,of 
carbonate  of  Hme. 

Symptoms. — The  case  is  seldom  seen  until  the  derangement  is  advanced. 
It  is  then,  usually,  as  has  been  said,  the  cough  which  excites  the  alarm  of 
the  parents.  The  cough  is  frequent  and  hard,  and  the  child  often  clears 
his  voice,  and  when  questioned  complains  that  he  has  a  "  tickling  "  in  his 
throat.  The  symptoms  vary  in  severity  from  time  to  time.  A^Tien  the  dis- 
ease is  severe,  the  cough  is  accompanied  by  pain  shooting  ujd  into  the 
head  or  ears.  It  often  comes  on  in  paroxysms,  and  these  are  apt  to  occur  in 
the  night.  There  is  also  an  uneasy  sensation  in  swallowing,  and  the  child 
may  complain  that  "  coughing  makes  his  throat  sore."  In  advanced  cases 
the  disease  extends  to  the  larynx,  producing  hoarseness,  and  into  the  Eus- 
tachian tubes,  causing  dulness  of  hearing.  If  the  posterior  nares  are  at- 
tacked, the  sense  of  smell  may  be  impaired  ;  if  the  soft  palate,  the  sense 


FOLLICULAR  PHARYNGITIS — SYMPTOMS — TREATMENT.      579 

of  taste  may  be  affected.  Loss  of  these  senses  is  not  common  in  the  child,  or 
is  difficult  to  ascertain  ;  but  a  certain  impairment  of  hearing  is  frequently- 
complained  of.  Indeed,  I  am  informed  by  Mr.  Reeves  that  of  the  children 
•who  are  brought  on  account  of  deafness  to  the  Ear  Department  of  the 
London  Hospital,  a  full  third  owe  their  infirmity  to  this  affection  of  the 
throat.  In  such  cases,  a  peculiar  flattening  of  the  nostrils  is  often  pro- 
duced, owing  to  the  swelling  of  the  posterior  nares.  The  appearance  is 
similar  to  that  which  has  been  so  often  remarked  upon  as  resulting  from 
a  chronic  enlargement  of  the  tonsils,  and  is  indeed  produced,  hke  it,  by 
the  disuse  of  the  nasal  passages  in  respiration.  Disease  of  the  middle  ear, 
with  discharge  from  the  meatus,  may  be  also  a  consequence  of  the  pharyn- 
geal affection.  A  catarrh  is  very  apt  to  spread  along  the  Eustachian  tube 
into  the  tympanum  ;  and  the  secretion  being  unable  to  escape  through  the 
occluded  tubes,  accumulates,  and  leads  to  ulceration  of  the  tympanic  mem- 
brane, and  otorrhoea. 

In  mild  cases  of  follicular  pharyngitis  there  is  little  interference  with 
deglutition  ;  but  when  the  disease  is  more  pronounced,  swallowing  may  be 
difficult  as  well  as  painful,  and  the  attempt  to  swallow  is  said  sometimes 
to  give  rise  to  spasm  of  the  pharynx. 

On  inspection  of  the  fauces,  we  find  small  eminences  scattered  over  the 
mucous  membrane  at  the  back  of  the  pharynx.  These  are  rounded  or 
elongated  in  shape,  and  may  be  so  numerous  as  to  present  a  granular  ap- 
pearance. Their  colour,  and  that  of  the  whole  mucous  membrane,  is  deeper 
than  natui'al,  and  enlarged  superficial  veins  may  be  seen  running  in  the 
depressions  between  the  prominent  follicles.  If  the  disease  is  extensive, 
similar  granules  are  found  on  the  pillars  of  the  fauces  and  on  the  tonsils. 
Sometimes  mucus,  more  or  less  stringy  and  turbid,  may  be  seen  clinging 
to  the  tonsils,  or  hanging  down  from  behind  the  soft  palate,  and  this  may 
be  mixed  up  with  yeUow-looking  exudation  from  the  diseased  foUicles. 

In  sci'ofulous  children,  ulceration  is  very  apt  to  occur.  The  ulcers  are 
seated  in  the  fohicles.  If  isolated,  they  are  small  and  circular,  but  when 
placed  closely  together,  they  are  larger  and  irregular  from  junction  of  the 
borders  of  neighbouring  sores.  The  uvula  is  elongated,  and  its  surface  is 
dotted  over  with  enlarged  glands. 

Diagnosis. — The  diagnosis  of  follicular  pharyngitis  presents  no  diffi- 
culty. If  the  patient  is  brought  on  account  of  cough,  examination  of  the 
chest  usually  reveals  no  sign  of  disease,  while  inspection  of  the  throat  dis- 
covers the  characteristic  granular  appearance  of  the  pharynx. 

Prognosis. —  In  children,  the  disease  can  usually  be  arrested  by  suitable 
treatment,  but  it  may  tend  to  recur  afterwards  from  sHght  exposure. 
Follicular  pharjoigitis  may  be  associated  with  phthisis,  and,  according  to 
Dr.  Horace  Green,  is  sometimes  a  cause  of  it. 

Ti^eatment. — As  childi-en  suffering  from  this  complaint  are  usually 
weakly  and  under-nourished,  the  general  health  must  be  first  attended  to, 
and  the  child  wiU  often  be  greatly  benefited  by  cod-liver  oil  and  tonics, 
such  as  iron  and  quinine.  A  little  sound  claret  diluted  with  water  may  be 
given  him  with  his  dinner.  In  fact,  the  constitutional  treatment  recom- 
mended in  cases  of  strongly  marked  strumous  diathesis  is  often  required. 

For  a  cure  of  the  local  disorder,  local  treatment  is  essential.  In  mild 
cases,  a  more  healthy  action  of  the  pharyngeal  mucous  membrane  may  be 
induced  by  astringent  applications,  especially  by  brushing  the  throat  two 
or  three  times  daily  with  the  glycerine  of  tannin,  or  vdth  equal  parts  of 
strong  perchloride  of  iron  and  glycerine.  Dr.  J.  Sawyer  speaks  highly  of 
the  local  application  of  borax.     A  saturated  solution  should  be  sprayed  into 


580  DISEASE   IN   CHILDREiq^. 

the  throat  for  several  minutes,  three  or  four  times  in  the  day,  at  an  interval 
after  food.  The  extract  of  eucalyptus,  in  the  form  of  a  lozenge,  is  also 
serviceable  when  secretion  is  copious. 

In  more  severe  cases,  it  may  be  necessary  tg  destroy  each  folhcle  sep- 
arately by  a  caustic  or  the  galvanic  cautery.  The  latter,  which  can  be  put 
cold  into  the  throat  and  rapidly  heated  in  situ,  is  no  doubt  the  most  con- 
venient. Moreover,  its  action  being  instantaneous,  the  application  is  less 
painful  than  that  of  the  more  slowly-acting  escharotic.  If  a  caustic  be  used, 
nitrate  of  silver,  properly  employed,  is  one  of  the  most  successful.  The 
throat  must  be  first  cleansed  witli  a  brush  soaked  in  warm  water  ;  then 
with  a  piece  of  lunar  caustic,  sharpened  to  a  fine  point,  each  enlarged  follicle 
or  ulcer  must  be  touched  separately.  The  number  of  foUicles  to  be  de- 
stroyed at  one  visit  must  vary  according  to  the  sensitiveness  of  the  child, 
and  the  distress  produced  by  the  application.  On  the  first  occasion,  only 
one  or  two  may  be  destroyed  as  a  trial  test. 

Instead  of  the  lunar  caustic,  other  caustics,  such  as  Dr.  Morell  Macken- 
zie's "London  paste,"  may  be  employed. 

HERPES  OF  THE  PHARYNX. 

Herpes  on  the  skin  is  a  common  eruption  in  the  child.  Sometimes  the 
rash  appears  on  the  pharynx,  and  produces  great  discomfort. 

Causation. — The  causes  of  herpes  are  doubtful.  The  complaint  is  said 
to  be  excited  by  exposure  to  cold,  but  a  constitutional  tendency  appears  to 
be  necessary  to  its  development.  There  is  no  doubt  that,  as  Trousseau 
first  pointed  out,  pharyngeal  herpes  is  especially  common  during  outbreaks 
of  diphtheria,  and  that  in  such  cases  the  zymotic  disease  may  become  en- 
grafted upon  the  herpetic  eruption. 

Symptoms. — The  complaint  begins  with  febrile  symptoms,  followed 
after  a  few  hours  by  soreness  of  the  throat.  The  child  complains  of  a 
painful  feeling  in  deglutition,  which  is  usually  distinctly  confined  to  one 
spot.  On  examination,  a  few  whitish  vesicles  are  seen  clustered  together 
on  the  soft  palate,  on  one  of  the  pillars  of  the  fauces,  or  on  one  of  the 
tonsils.  Around  them,  the  mucous  membrane  is  redder  than  natural,  and 
swollen.  Sometimes  the  vesicles  are  more  numerous,  and  more  generally 
distributed.  The  vesicles  last  from  twenty-four  to  forty-eight  hours,  and 
may  then  disappear  without  rupture,  or  burst,  leaving  httle  white  spots 
from  macerated  epithelium,  or  circular  ulcers  which  soon  heal.  Some- 
times, instead  of  heahng  rapidly,  the  ulcers  become  covered  with  pulta- 
ceous  exudation,  and,  if  the  sores  are  numerous,  the  exudation  may  form  a 
continuous  layer.  More  usually,  however,  the  patches  are  small  and  iso- 
lated. Their  seat  is  generally  the  soft  palate,  or  one  tonsil ;  seldom  the 
back  of  the  pharynx.  After  three  or  four  days  the  exudation  becomes  de- 
tached and  disappears.  Sometimes  more  than  one  crop  of  vesicles  is  no- 
ticed. Often,  herpes  of  the  pharynx  is  associated  with  the  same  condition 
of  the  lip  ;  and  the  vesicles  are  said  sometimes  to  invade  the  larynx  and 
the  openings  of  the  Eustachian  tubes,  so  as  to  affect  the  respiration  and 
the  sense  of  hearing. 

Diagnosis. — When  the  disease  is  seen  in  the  vesicular  stage  it  is  readily 
recognised.  If,  however,  inspection  is  delayed  until  the  patches  of  exuda- 
tion have  formed,  the  case  may  be  mistaken  for  one  of  diphtheria  ;  more 
especially,  as  this  form  of  the  complaint  is  often  associated  with  outbreaks 
of  that  disease.  If,  however,  herpes  of  the  lip  is  present,  and  especially  if 
small  circular  ulcers  can  be  seen  mixed  up  with  the  small  patches  of  exu- 


HERPES  OF   THE  PHARYNX — TUBERCULAR  PHARYNGITIS.       581 

dation,  we  may  suspect  pharyngeal  herpes.     Still,  it  is  often  impossible  to 
distinguish  the  case  from  a  mild  attack  of  diphtheria. 

Treatment. — The  complaint  requires  Uttle  treatment.  Attention  must 
be  paid  to  the  bowels.  If  the  tongue  is  furred,  it  is  well  to  administer  a 
mercurial  purge,  such  as  a  grain  of  calomel  with  two  or  three  grains  of 
jalapine.  While  the  pyrexia  lasts,  the  child  should  be  kept  in  bed  and  put 
upon  slops — indeed,  the  pain  induced  by  deglutition  will  prevent  his  wish- 
ing to  swallow  solid  food.  If  the  fever  is  high,  tincture  of  aconite  may  be 
given  in  doses  of  one  or  two  drops,  every  hour,  or  two  hours.  If  the  dis- 
comfort in  the  throat  is  great,  it  may  be  relieved  by  inhalations  of  steam, 
medicated  with  compound  tincture  of  benzoin  (  3  j.  to  the  pint).  If  in  the 
stage  of  exudation  there  is  any  foetor  of  the  breath,  inhalations  or  sprays 
containing  creasote  or  carbolic  acid  (TTL  xx.  of  each  to  the  pint)  may  be 
made  use  of.  As  an  internal  remedy  for  children,  Dr.  Morell  Mackenzie 
speaks  highly  of  arsenic.  Three  or  four  drops  of  Fowler's  solution  may 
be  given  three  times  a  day,  directly  after  food,  to  a  child  five  years  of  age. 
If  there  is  any  doubt  as  to  the  nature  of  the  complaint,  and  diphtheria  be 
epidemic  in  the  neighbourhood,  the  treatment  for  that  disease  should  be 
at  once  adopted. 

TUBERCULAR  PHARYNGITIS. 

In  children,  the  subjects  of  tuberculosis,  the  pharynx,  like  any  other  part 
of  the  body,  may  become  affected  as  a  consequence  of  the  diathetic  state. 
The  pharyngeal  complaint  is  only  a  part  of  the  general  disease  ;  but  it  may 
occur  in  children  in  whom  no  pulmonary  symptoms  are  present,  and  in 
subjects  who  have  not  previously  suffered  from  delicacy  of  the  throat. 

Morbid  Anatomy. — The  mucous  membrane  is  the  seat  of  ulceration, 
which  is  limited  at  first  to  one  side  of  the  fauces.  The  ulcers  are  due  to 
the  caseation  and  breaking  down  of  gray  granulations  themselves,  and  not 
to  the  development  of  these  granules  around  a  sore  formed  by  the  disin- 
tegration of  ordinary  cheesy  matter,  such  as  may  result  from  proliferation 
of  the  cellular  contents  of  a  glandular  folhcle.  Frankel  states  that  in  a 
previously  sound  portion  of  the  velum  palati  he  has  been  able  to  follow  the 
whole  process  with  the  eye.  Thus  the  gray  nodules  have  spmng  up,  have 
become  caseous  and  disintegrated,  and  have  been  replaced  by  ulcers  under 
his  own  immediate  observation.  On  microscopic  examination,  the  base  of 
the  ulcer  is  seen  to  be  infiltrated  with  round  cells,  which  permeate  the 
sub-mucous  tissue,  and  even  reach  to  the  muscles.  The  same  cells  also 
infiltrate  the  cellular  tissue  of  the  glandulse.  The  special  gland  cells  are 
often  in  a  state  of  fatty  degeneration,  and  tend  to  become  cheesy. 

The  other  organs  of  the  body  are  also  the  seat  of  the  gray  granulation. 

Symptoms. — The  first  symptom  pointing  to  the  throat  is  soreness,  and 
this  seems  to  be  exceptionally  severe,  for  the  child  makes  it  the  subject  of 
continual  complaint.  In  deglutition  the  pain  often  shoots  up  to  the  ears, 
and  usually  becomes  so  great  on  taking  solids  that  no  jDersuasions  can  in- 
duce the  child  to  swallow  anything  but  liquid  food.  In  addition  to  pain, 
there  is  sometimes  difficulty  in  deglutition,  and  hquids  may  return  through 
the  mouth  and  nose. 

On  examination  of  the  throat,  the  mucous  membrane  is  seen  to  be  ul- 
cerated. The  ulcers  generally  begin  on  one  side — on  the  tonsil  or  one  of 
the  pillars  of  the  fauces,  and  spread  slowly  to  the  soft  and  hard  palate  and 
the  back  of  the  pharynx.  According  to  Frankel,  they  begin  as  gray  isolated 
or  confluent  nodules,  which  afterwards  undergo  caseous  degeneration  and 
ulceration.     They  tend  to  spread  transversely  rather  than  in  a  vertical  di- 


582  DISEASE   IjS"   CHILDREN. 

rection,  and  seldom  penetrate  deeply  into  the  tissues.  The  floor  of  the 
ulcer  is  irregular  and  cheesy  ;  the  borders  are  congested  and  undermined. 
In  the  neighbourhood  of  the  sores,  gray  mihary  nodules  can  be  distinctly 
seen  dotting  the  mucous  membrane.  If  the  uvula  is  not  invaded  by  the 
destructive  process,  it  often  becomes  atrophied.  In  the  opposite  case,  it 
swells  to  a  considerable  thickness,  and  may  be  dotted  over  with  hard  nod- 
ules.    Eventually  it  may  be  eaten  away. 

The  ulceration  may  spread  extensively.  In  a  case  reported  by  Dr.  Gee 
— a  child  six  years  old — the  whole  of  the  pharynx  down  to  its  union  with 
the  gullet  was  covered  with  yellow  purulent  matter.  The  mucous  mem- 
brane was  extensively  destroyed,  so  as  to  lay  bare  the  pharyngeal  muscles. 
The  soft  palate,  back  and  front,  was  in  the  same  condition.  The  uvula  was 
destroyed,  as  well  as  the  mucous  membrane  of  the  tongue,  half  way  to  the 
foramen  caecum.  The  right  tonsil  was  gone,  and  the  ary-epiglottidean 
folds  were  ulcerated  superficially.  The  true  vocal  cords  and  the  larynx 
below  them  were  unaffected. 

As  a  consequence  of  the  ulceration,  the  voice  acquires  a  nasal  quality, 
as  it  does  in  most  cases  of  pharyngitis.  The  glands  of  the  neck  become 
enlarged  along  the  borders  of  the  sterno-mastoid  muscles,  and  at  the  angles 
of  the  jaw. 

When  the  case  is  first  seen,  the  general  nutrition  of  the  child  is  not 
necessarily  unsatisfactory.  The  degree  to  which  it  is  impaired  depends  in 
a  great  measure  upon  the  period  at  which  the  pharyngeal  affection  arises 
in  the  general  disease.  If  it  occur  early,  the  child,  although  thin,  is  not 
emaciated.  His  thinness  is  no  doubt  chiefly  due  to  the  influence  of  the 
cachexia  upon  nutrition,  but  is  probably  also  in  part  the  consequence  of  dif- 
ficulty and  pain  in  swallowing,  which  is  a  bar  to  the  taking  of  suf&cient  food. 
The  general  symptoms  are  those  of  tuberculosis.  There  is  fever,  but  sel- 
dom a  very  high  temperature,  the  evening  rise  not  often  passing  beyond 
102^  or  103°.  There  is  usually  cough,  and  an  examination  of  the  chest 
may  detect  signs  of  consolidation  ;  but  in  some  cases  no  evidence  of  tuber- 
cle can  be  discovered  at  first  in  either  the  chest  or  the  abdomen.  As  the 
disease  advances,  however,  signs  of  mischief  become  manifest  in  other  parts. 
of  the  body.  Spots  of  dulness  may  be  discovered  at  the  apices  of  the 
lungs ;  a  secondary  catarrhal  pneumonia  becomes  developed ;  signs  of 
tubercular  peritonitis  are  to  be  discerned,  or  symptoms  of  tubercular  men- 
ingitis occur ;  and  sometimes  a  persistent  purging  is  set  up,  with  all  the 
signs  of  tubercular  ulceration  of  the  intestines. 

Diagnosis. — The  chief  difficulty  in  the  diagnosis  of  tubercle  of  the 
pharynx  Hes  in  separating  it  from  syphilitic  ulceration  of  the  same  part. 
The  distinction  is,  however,  easier  in  the  child  than  it  is  in  the  adult,  for 
in  young  subjects  the  latter  disease  is  almost  invariably  a  congenital  mal- 
ady. E,  then,  by  careful  questioning  of  the  parents,  we  can  find  no  history 
of  miscai-riages  on  the  part  of  the  mother,  or  of  syphilitic  symptoms  in  the 
patient  himself  shortly  after  birth  ;  if  the  child  bear  about  him  nt)  evidence 
of  past  syphihtie  disease,  such  as  flattened  bridge  of  the  nose,  small  pits, 
and  hnear  cicatrices  about  the  angles  of  the  mouth,  prominence  of  the  fore- 
head, opacity  of  the  cornea,  or  enlargement  of  the  spleen  ;  if,  too,  the  per- 
manent incisors  have  appeared  and  show  no  sign  of  malformation — in  such 
a  case  we  may  exclude  syphilis  with  tolerable  certainty.  If,  on  the  other 
hand,  a  hereditary  tendency  to  phthisis  can  be  discovered,  or  if  other  chil- 
dren of  the  family  have  died  with  symptoms  of  tubercular  meningitis,  the 
evidence  is  in  favour  of  tubercle.  Still,  a  history  of  syphihs,  although  point- 
ing strongly  to  this  cause  for  the  ulceration,  does  not  make  it  certain  that 


TUBEECULAE  PHAEYNGITIS — DIAGNOSIS — TEEATMENT.      583 

the  pharyngeal  disease  is  a  result  of  the  venereal  taint,  for  a  syphiHtic  child 
may  fall  a  victim  to  tuberculosis.  Nor,  again,  if  signs  of  tubercle  are  to  be 
discovered  in  other  organs,  can  we,  from  this  circumstance  alone,  positively 
exclude  a  syphilitic  origin  of  the  throat  lesion,  unless  we  are  supported  in 
this  judgment  by  the  family  and  personal  history  of  the  child.  Fortunately, 
however,  careful  observations  of  the  fauces  itself  furnishes  sufficient  evi- 
dence. In  syphilis,  the  ulcers  have  sharper  edges,  penetrate  more  deeply, 
tend  to  produce  contractile  scars,  and  have  no  gray  nodules  in  their  neigh- 
bourhood. Tuberculous  ulcers,  as  has  been  already  remarked,  are  super- 
ficial, as  a  rule,  with  irregular  nodular,  eroded,  and  undermined  edges, 
and  a  cheesy  floor.  In  their  neighbourhood,  gray  miliary  nodules  are 
seen  underneath  the  epitheHum.  Moreover,  in  tuberculosis,  the  ulceration 
spreads  very  slowly,  and  the  cervical  glands  are  invariably  enlarged.  In 
syphilis,  the  extension  is  more  rapid,  and  the  glands  of  the  neck  are  rarely 
indurated  and  swollen.  Again,  syphilitic  ulceration  is  not  accompanied  by 
fever,  while  in  tubercular  pharyngitis  the  temperature  is  always  elevated. 
The  diagnosis  will  therefore  rest  upon  the  complete  absence  of  all  syphilitic 
history,  either  family  or  personal ;  the  appearance  of  the  sores  themselves, 
with  the  gray  mihary  nodules  in  their  neighbourhood ;  the  enlargement 
of  the  superficial  glands,  and  the  presence  of  fever. 

Prognosis. — The  disease  is  always  fatal ;  and,  indeed,  the  pharyngeal 
lesion  tends  to  hasten  the  end  by  the  rapid  exhaustion  it  induces  through 
the  difficulty  of  supplying  a  sufficient  quantity  of  nourishment.  Death 
usually  occurs  in  from  two  to  six  months. 

Treatment. — Little  can  be  done  in  the  way  of  treatment  in  retarding 
the  downward  course  of  the  illness.  Nutritious  food  in  small  bulk,  such 
as  meat  essence,  pounded  meat  made  liquid  with  gravy,  yolks  of  egg,  milk, 
etc.,  should  be  given ;  and  the  strength  of  the  patient  may  be  also  sup- 
ported by  doses  of  the  brandy-and-egg  mixture  or  port  wine.  If  the  child 
be  unwilling  or  unable  to  swallow,  nourishment  must  be  administered  by 
the  stomach-tube  passed  through  the  nose. 

We  must  endeavoiu'  to  relieve  the  distress  of  the  child  by  soothing  ap- 
plications. Brushing  the  affected  part  with  glycerole  of  morphia  is  recom- 
mended by  Isambert.  For  a  child  of  seven  or  eight  years  old,  the  strength 
of  the  application  may  be  one  grain  in  three  drachms.  Inhalations  of 
steam  also  appear  to  reheve. 


CHAPTER  YI. 

QUINSY. 

Acute  inflammation  of  tlie  tonsils,  or  quinsy,  is  a  frequent  complaint  of 
later  childhood,  but  is  comparatively  rarely  met  with  during  the  first  few 
years  of  life.  One  of  the  peculiarities  of  the  affection  is  its  disposition  to 
recur.  A  first  attack  leaves  behind  it  a  tendency  to  a  second,  and  the 
same  subject  will  be  found  to  suffer  from  the  disease  again  and  again  under 
the  influence  of  apparently  trivial  causes.  A  common  consequence  of 
these  repeated  attacks  is  a  hypertrophied  condition  of  the  tonsils.  This 
may  be  a  source  of  great  inconvenience,  and  may  even  have  a  serious  ef- 
fect upon  the  health  and  general  development  of  the  child. 

The  tonsils  are  often  found  to  share  in  a  general  inflammation  affecting 
the  mucous  membrane  of  the  mouth  and  fauces,  and  in  scarlatina  and 
diphtheria  they  are  almost  invariably  inflamed  and  swollen.  The  name 
"  quinsy  "  is,  however,  apphed  to  a  special  primary  affection  which  appears 
to  be  something  more  than  a  mere  local  complaint.  Acute  tonsillitis  has, 
indeed,  been  compared  to  croupous  pneumonia — another  disease  which  is 
no  longer  regarded  as  a  purely  local  inflammation.  In  each  of  these  forms 
of  illness,  we  find  general  symptoms  severe  out  of  all  proportion  to  the 
local  lesion  ;  a  rapid  rise  of  temperature  which  often  precedes  the  more 
special  symptoms,  and  a  critical  fall  on  the  fifth  or  sixth  day.  In  each  dis- 
ease, too,  the  attack  appears  to  be  due  to  very  similar  causes. 

Causation. — Although  occasionally  met  with  in  young  children,  quinsy 
cannot  be  said  to  be  common  until  about  the  eighth  or  ninth  years.  In  all 
cases  there  is  probably  a  special  individual  susceptibility  rendering  the 
patient  more  liable  to  be  affected  by  cold  and  damp,  which  appear  to  be 
the  ordinary  causes  of  catarrh.  Any  influence  which  exercises  a  depressing 
effect  upon  the  system  will  no  doubt  assist  the  action  of  these  causes,  and 
some  observers  are  disposed  to  believe  that  in  unfavourable  subjects  such 
depressing  influences  alone  are  capable  of  exciting  the  attack.  There  ap- 
pears to  be  a  distinct  connection  between  tonsillitis  and  acute  rheumatism. 
Quinsy  is  common  in  rheumatic  subjects,  and  attacks  of  rheumatism  are 
often  preceded  by  acute  inflammation  of  the  tonsils.  Indeed,  so  frequently 
is  this  the  case  that  quinsy  has  been  looked  upon  as  an  early  manifestation 
of  the  rheumatic  tendency. 

The  inhalation  of  sewer  gas  is  another  common  cause  of  tonsillitis. 
Inmates  of  houses  where  the  waste-water  pipes  run  directly  into  the  soil- 
pipe,  or  where  the  main  soil-pipe  is  defective  and  leaks  under  the  basement 
floor,  are  often  subject  to  repeated  attacks  of  quiusy,  and  also  to  a  slower 
inflammation  of  the  tonsils,  which  resists  all  treatment  as  long  as  the  pa- 
tient remains  in  the  vitiated  atmosphere. 

Chronic  hjqDcrtrophy  of  the  tonsils  is  not  always  the  consequence  of 
the  acute  form  of  the  disease.  In  scrofulous  children,  enlargement  of  these 
glands  may  arise  from  a  process  of  slow  inflammation.     The  same  thing  is 


QUINSY — CAUSATION — MORBID    ANATOMY — SYMPTOMS.      585 

occasionally  seen  in  children  in  whom  no  hereditary  diathetic  tendency  can 
be  discovered,  and  in  families  where  the  other  members  are  strong  and 
healthy.  In  these  cases  it  will  be  generally  found  that  the  patient,  if  he 
has  not  suffered  from  repeated  attacks  of  the  acute  form  of  the  disease, 
has  been  long  exposed  to  insanitary  or  other  depressing  influences  by  which 
his  development  and  general  nutrition  have  sustained  distinct  injury. 
The  chUd  may  have  Hved  in  a  vitiated  atmosphere,  been  overworked  at 
school,  or  been  subjected  to  other  sources  of  depression  which  have  reduced 
his  strength  and  diminished  his  vital  powers. 

The  chronic  inflammation  of  the  tonsils,  which  is  the  consequence  of  a 
diathetic  tendency,  is  seldom  seen  before  the  fifth  or  sixth  year.  "When  the 
hypertrophy  occurs  in  children  of  healthier  constitution,  it  often  begins 
earUer,  being  found  in  infants  under  twelve  or  eighteen  months  old.  It 
has  been  suggested  bj^  Robert,  that  in  such  young  subjects  the  enlargement 
may  be  a  consequence  of  teething,  and  it  is  possible  that  the  change  in  the 
tonsils  may  have  some  connection  with  the  general  glandular  activity  which 
is  known  to  prevail  at  this  period  of  hf  e. 

Morbid  Anatomy. — In  acute  tonsillitis,  the  inflamed  tonsil  becomes  swol- 
len with  inflammatory  exudation.  An  increased  production  of  epithelial 
cells  takes  place  in  the  recesses  of  the  gland.  The  crypts  are  distended 
with  them,  and  the  cells  appear  as  creamy-looking  masses  at  the  orifices. 
Almost  at  the  same  time  the  lymphatic  follicles  swell  and  soften,  and  form 
abscesses  which  run  together  so  as  to  give  rise  to  a  considerable  collection 
of  pus.  This  is  eventually  expelled  by  one  or  more  openings.  The  inflam- 
mation then  subsides,  and  the  swelling  more  or  less  completely  disappears. 
It  seldom  happens  that  both  tonsils  are  attacked  at  exactly  the  same  time. 
Usually,  the  inflammation  begins  first  on  one  side,  and  partly  runs  its  course 
before  the  tonsil  on  the  other  side  begins  to  suffer.  There  is  also  more  or 
less  inflammation  of  the  soft  palate  and  pillars  of  the  fauces,  and  the  salivary 
glands  may  participate  in  the  inflammation  and  get  hard  and  swollen. 

In  tonsils  permanently  enlarged  from  chronic  inflammation,  the  increase 
in  size  is  due  to  an  inflammatory  hypertrophy  of  the  sub-mucous  connec- 
tive tissue.  The  glands  are  enlarged  and  hard,  and  their  surface  is  often 
Uneven. 

Symptoms. — The  inflammation  begins  with  a  chill,  or  even  a  distinct 
rigor,  and  the  child  complains  of  a  feeling  of  dryness  and  aching  in  the 
region  of  the  fauces.  His  temperature  rises  to  between  102°  and  103°, 
and  he  looks  and  feels  iU.  Often  there  is  general  aching  and  soreness  of 
the  body,  such  as  is  experienced  at  the  beginning  of  attacks  of  severe 
catarrh  ;  the  pulse  is  rapid  and  full,  and  the  tongue  is  thickly-coated  with 
fur.  On  inspection  of  the  throat,  the  tonsils  are  seen  to  be  swollen  and 
vividly  red,  and  there  is  also  redness  of  the  soft  palate,  uvula,  and  piUars 
of  the  fauces.  The  uvula  is  not,  however,  swoUen  at  the  first,  although 
later  it  is  apt  to  become  oedematous. 

As  the  inflammatory  process  increases,  the  pain  and  achiug  at  the  back 
of  the  throat  grow  more  distressing,  and  the  discomfort  is  increased  by  a 
secretion  of  thick  mucus  from  the  inflamed  mucous  membrane.  Degluti- 
tion is  accompanied  by  a  sharp  pain,  which  often  shoots  up  into  the  ears 
and  side  of  the  head,  and  all  movement  of  the  jaws  is  painful.  The  child 
is  afraid  or  unable  to  swallow,  and  often  an  attempt  to  do  so  produces  a 
choking  sensation,  and  a  return  of  the  fluid  thi-ough  the  nose.  Singing  in 
the  ears  and  deafness  are  often  present,  and  the  voice  of  the  sufferer  has  a 
peculiar  nasal  quahty  which  is  very  characteristic.  At  the  height  of  the 
disease,  the  temperatm-e  is  often  as  high  as  104°  ;  the  skin  is  moist  and 


586  DISEASE   IN   CHILDEElSr. 

clammy  ;  the  pulse  is  rapid  and  compressible  ;  there  is  a  feeling  of  great 
prostration,  and  the  face  is  pale,  haggard,  and  distressed. 

If  one  tonsil  only  be  affected,  at  the  end  of  five  or  six  days  a  yellowish 
spot  can  be  detected  on  the  reddened  and  glossy  sui'face  of  the  gland.  In 
a  few  hours,  or  on  the  following  day,  the  abscess  bursts  at  this  point,  and 
discharges  a  large  quantity  of  thick  pus,  to  the  great  and  almost  immediate 
reUef  of  the  patient.  Often,  however,  at  this  time,  or  shortly  before,  the 
opposite  tonsil  begins  to  swell,  and  the  discomfort,  if  it  had  partially  abated, 
returns. 

The  swollen  gland  may  reach  a  large  size.  It  can  be  felt  externally 
behind  the  angle  of  the  jaw,  and  often  seems  to  block  up  the  whole  pas- 
sage of  the  throat.  When  the  inflammation  runs  its  course  on  both  sides 
at  the  same  time,  there  may  be  difficiilty  of  breathing,  and  the  face  assumes 
an  agonized  expression  of  distress.  Fortunately,  any  but  a  favom-able  ter- 
mination to  the  complaint  is  excessively  rare  ;  and  the  child's  friends  may 
be  comforted  by  the  assui-ance  that  the  severity  of  the  symptoms  is  out  of 
all  proportion  to  the  actual  danger  of  the  iUness,  and  that  recovery  may  be 
expected  with  confidence.  "When  the  abscess  biu-sts,  its  purulent  contents 
are  almost  invariably  swallowed  by  the  child  ;  but  the  cessation  of  much  of 
his  distress,  the  rehef  shown  in  his  face,  the  rapid  fall  of  temperature,  and 
the  improvement  in  his  general  symptoms,  allow  us  to  infer,  even  with- 
out examination  of  the  throat,  that  evacuation  of  the  matter  has  occurred. 

After  discharge  of  its  contents  the  gland  begins  to  diminish  in  size  ; 
deglutition,  although  still  painful,  is  accomplished  with  greater  ease  ;  the 
haggard  expression  of  the  face  disappears,  and  the  desire  for  food  begins 
to  return.  Often,  at  this  time,  a  discharge  of  blood  takes  place  from  the 
abscess.  The  ajDpearance  of  blood  from  the  mouth  may  be  a  cause  of  great 
alarm  to  the  child's  relatives,  and  it  is  well  to  warn  them  of  the  possibility 
of  its  occurrence. 

The  diu-ation  of  the  disease  is  from  one  to  two  weeks,  according  to 
whether  both  tonsils  or  only  one  becomes  inflamed.  Convalescence  is 
short,  and  after  the  cessation  of  the  attack,  the  child  quickly  recovers  his 
strength. 

In  a  considerable  proportion  of  cases,  especially  if  judicious  treatment 
is  early  adopted,  the  inflammatory  process  stops  short  of  suppuration.  The 
redness  then  begins  to  diminish,  and  the  swelling  to  subside,  at  the  end  of 
forty-eight  hours,  or  in  the  course  of  the  fourth  day.  In  many  of  these 
instances,  the  red  and  swollen  tonsils  are  speckled  over  with  gray  patches 
from  the  secretion  at  the  mouths  of  the  foUicles,  and  sometimes  shallow 
ulcers  are  seen  on  the  inside  of  the  cheeks  and  hps,  or  on  the  tongue,  but 
rarely  on  the  tonsils  themselves.  In  this  form  of  the  disease,  the  febrile 
action  is  less  high  than  in  the  suppurative  variety,  but  the  dej)ression  and 
feeling  of  iUness  are  fully  as  severe.  When  occurring  in  this  form,  tonsil- 
litis is  probably  always  a  consequence  of  insanitary  conditions.  The  cases 
are  often  met  with  in  groups,  several  inmates  of  the  same  house  or  row  of 
houses  being  attacked  almost  at  the  same  time.  Although  included  under 
the  name  of  quinsy,  the  disease  is  probably  distinct  in  its  nature  from  the 
suppurative  variety,  and,  if  suitable  treatment  be  adopted  early,  it  can  be 
readily  arrested. 

In  chronic  hypertrojphy  of  the  tonsils,  the  glands  are  enlarged  and  hard. 
They  can  be  felt  externally  behind  the  angle  of  the  jaw,  and,  on  inspection 
of  the  throat,  are  seen  as  two  globular  bodies  projecting  towards  one  an- 
other, so  as  almost  to  touch  in  the  middle  of  the  throat.  The  anterior  sur- 
face is  smooth  and  shining,  but  the  internal  face  is  ii-regular  from  the  open- 


QUINSY — SYMPTOMS.  587 

ings  of  the  glandular  recesses.  Their  colour  is  usually  of  a  pale  brick  red, 
but  when  at  all  congested,  as  they  are  apt  to  be  on  the  occurrence  of  the 
slightestTchiU,  they  become  of  a  deeper  tint,  and  yellow  curdy  masses  appear 
at  the  orifices  of  the  crypts.  At  these  times,  they  often  meet  in  the  middle 
line,  and  the  friction  of  the  two  bodies  against  one  another  may,  as  Dr. 
Gr.  V.  Poore  has  pointed  out,  be  a  cause  of  superficial  ulceration.  One  of 
the  results  of  this  chronic  enlargement  of  the  glands  is  the  frequent  recur- 
rence of  attacks  of  inflammation,  which,  although  amounting  to  no  more 
than  superficial  pharyngitis,  are  yet  a  source  of  great  discomfort.  Usually, 
at  least  once  in  the  twelve  months,  the  inflammatory  process  is  more  severe, 
and  the  patient  passes  through  a  regular  attack  of  quinsy. 

A  child  who  suffers  fi'om  this  chronic  enlargement  of  the  tonsils,  presents 
many  very  characteristic  symptoms.  He  has  often  an  unhealthy  appearance, 
being  undersized,  pale,  and  thin.  The  imperfect  state  of  nutrition  in  such 
patients  is  well  seen  in  cases  where  one  member  of  a  family  is  alone  af- 
fected. The  frail  aj)pearance  of  the  child  then  contrasts  strikingly  with 
the  robust  and  healthy  look  of  his  more  fortunate  brothers  and  sisters.  It 
has  been  supposed  that  this  imperfect  performance  of  the  nutritive  pro- 
cesses is  due  to  the  impediment  to  respiration  set  up  by  the  swollen  bodies, 
and  the  consequent  insufficient  combustion  of  waste-products  in  the  body. 
I  cannot,  however,  think  this  a  satisfactory  explanation  of  the  phenomenon. 
It  appears  to  me  to  be  rather  the  result  of  the  striking  susceptibility  to 
chills  almost  invariably  manifested  by  these  patients.  Their  gastric  mu- 
cous membrane  is  therefore  kept  in  a  state  of  almost  continual  catarrh.  As 
a  consequence,  digestion  is  laboured  and  imperfect,  and  the  nutritive  needs 
of  the  system  are  insufficiently  supplied.  Such  children  are  often  exces- 
sively irritable  and  restless.  Their  complexion  is  sallow,  with  a  dark  dis- 
colouration under  the  eyes.  They  sleep  badly  at  night,  dreaming  and  talk- 
ing incoherently.  Their  bowels  are  often  confined,  and  their  stools  light- 
coloured  and  offensive.  Sometimes  the  face  turns  suddenly  white,  and 
the  child  complains  of  flatulent  pains  and  of  distention  of  the  belly. 

In  all  cases  where  the  enlargement  of  the  glands  is  at  all  considerable, 
the  mucous  membrane  in  the  neighbourhood  of  the  tonsils  is  habitually 
congested  and  relaxed.  The  child  snores  in  his  sleep  ;  speaks  with  a  thick 
nasal  tone  of  voice,  and  may  be  dull  of  hearing  from  the  turgid  state  of 
his  Eustachian  tubes.  Slight  haemorrhages  often  occur  at  night  from  the 
surface  of  the  glands,  and  blood-stained  saliva  may  flow  from  the  child's 
open  mouth  on  to  the  pillow.  Sometimes  the  posterior  nares  are  almost 
completely  closed  to  the  passage  of  air.  The  nostrils  then  become 
flattened  so  as  to  narrow  the  nasal  apertures.  In  such  children,  the  palate 
is  often  high  and  arched  ;  the  upper  jaw  is  small ;  the  teeth  are  crowded 
and  overlap,  and  the  front  of  the  jaw  is  curiously  rounded  at  the  lips. 

In  extreme  cases,  the  entrance  of  air  through  the  larynx  is  imj)eded  ; 
often  sufficiently  so  to  induce  a  state  of  permanent  collapse  at  the  bases  of 
the  lungs.  The  lower  end  of  the  sternum,  with  the  cartilages  connected  with 
it,  is  then  forced  backwards  so  as  to  present  a  cup-shaped  depression  at 
that  point.  The  upper  portion  of  the  sternum  is  made  prominent,  and  one 
form  of  pigeon-breast  is  produced.  This  variety  of  the  pigeon-breast  may 
be  readily  distinguished  from  a  somewhat  similar  condition  in  the  rickety 
child.  In  the  latter,  the  whole  sternum  protrudes,  from  softening  of  the 
ribs.  In  the  former,  the  upper  part  of  the  breast-bone  is  prominent,  and 
the  depression  at  the  lower  part  is  the  result  of  yielding,  not  in  the  ribs, 
but  in  the  cartilages. 

Foetor  of  the  breath  is  a  common  consequence  of  enlarged  tonsils,  foi 


588  DISEASE  IN   CHILDEEN. 

the  glandular  recesses  become  filled  -with  a  cheesy,  decomposing  secretion. 
Congh  is  also  a  frequent  symptom  It  is  often  distressing  and  paroxysmal, 
and  when  combined  with  the  pallid,  weakly  appearance  above  referred  to, 
may  give  rise  to  fears  of  consumption.  Such  apprehensions  are  sometimes 
rather  confirmed  than  allayed  by  the  results  of  a  physical  examination  of 
the  chest.  In  many  such  cases,  a  peculiar  hollow  quality  of  breath-sound, 
probably  conducted  from  the  pharynx,  is  heard  with  the  stethoscope  at  each 
supra-spinous  fossa.  To  an  inexperienced  observer,  this  sign  may  sug- 
gest consolidation  of  the  lungs.  There  is,  however,  no  dulness  on  percus- 
sion, and  the  abnormal  quality  of  breath-sound  is  heard  principally  in  ex- 
piration, and  is  greatly  diminished,  or  even  completely  suppressed,  when 
the  child  opens  his  mouth  widely. 

Diagnosis. — Primary  inflammation  of  the  tonsils  can  only  be  mistaken 
for  the  secondary  inflammation  which  occurs  in  scarlatina  and  diphtheria. 
In  the  first  case,  the  absence  of  the  characteristic  eruption  at  the  end  of 
twenty-four  hoiu's  is  quite  sufiicient  to  exclude  the  infectious  fever.  But, 
besides  the  rash,  the  appearance  of  the  inflamed  mucous  membrane  is  very 
different  in  the  two  diseases.  In  scarlatina,  it  is  more  widely  diffused,  and 
of  a  more  brilliant  red,  than  at  the  beginning  of  quinsy  ;  and  on  the  soft 
palate  the  redness  is  usually  jDunctiform,  which  is  not  the  case  in  tonsillitis. 
In  diphtheria,  the  ash-coloured  leathery  appearance  of  the  false  mem- 
brane is  different  from  the  curdy  patches  of  quinsy  ;  and  in  the  former 
disease  there  is  early  swelling  of  the  cervical  glands.  In  inflammation  of 
the  tonsils  these  glands  are  not  usually  affected. 

Prognosis. — In  quinsy,  the  prognosis  is  rarely  otherwise  than  favourable. 
Cases  are  said  occasionally  to  have  happened  in  which  suffocation  has  re- 
sulted from  the  inflammation.  Eilliet  and  Barthez  have  referred  to  such  a 
case,  in  which  a  little  girl,  aged  thirteen,  died  of  suffocation  on  the  second 
day  ;  but  it  is  very  doubtful  if  this  was  an  uncomplicated  case  of  quins}^, 
and  the  accident  is  one  not  greatly  to  be  dreaded. 

In  cases  of  chronic  enlargement  of  the  tonsils,  the  glands,  if  left  alone, 
usually  become  smaller  after  puberty.  But  while  they  remain  swollen  they 
give  rise  to  so  much  inconvenience  as  well  as  induce  so  much  interference 
with  the  nutritive  processes,  that  measures  should  be  always  adopted  for 
their  early  reduction  or  removal. 

Treatment. — In  every  case  of  quinsy  it  is  ad-^/isable,  as  an  important 
preliminary  to  further  treatment,  to  clear  out  the  bowels  with  a  good  mer- 
curial purge,  followed  by  a  sahne  draught.  Linseed-meal  poultices,  or  a 
cold  water  com.press,  must  be  kept  apjDlied  to  the  throat,  and  if  old  enough 
to  gargle,  the  child  may  use  a  weak  solution  of  chlorate  of  potash  sweetened 
with  glycerine.  If  the  case  is  seen  early,  aconite  given  frequently,  in  very 
small  closes,  is  found  in  many  cases  to  have  a  distinctly  beneficial  effect. 
It  reduces  the  temjoerature,  promotes  the  action  of  the  skin,  and  often 
quickly  brings  the  inflammation  to  a  close.  The  tincture  should  be  used 
in  doses  of  one  drop  in  a  teaspoonful  of  water  every  hour.  Guaiacum  is 
greatly  praised  by  some  authors.  It  can  be  given  in  doses  of  three  or 
four  grains  in  a  teaspoonful  of  glycerine  several  times  in  the  day  ;  or  the 
child  may  suck  a  guaiacum  lozenge  every  three  or  four  hours.  The  salicy- 
late of  soda  is  another  remedy  which  has  been  lately  held  up  as  a  specific 
in  certain  cases  of  quinsy.  This  drug,  hke  the  preceding,  is  especially 
adapted  for  cases  which  arise  imder  the  influence  of  cold  and  damj),  and 
may  therefore  be  supposed  to  be  allied  in  their  natiu^e  to  rheumatism.  To 
a  child  of  ten  years  old  it  may  be  given  in  doses  of  ten  or  fifteen  grains 
every  four  hours  ;  or  half  that  quantity  every  two  hours.     If  the  salt  be 


QUIIN^SY — PROGNOSIS — TREATMENT.  •  589 

suspended  in  mucilage  flavoured  with  tincture  of  orange  peel,  and  sweet- 
ened with  spirits  of  chloroform,  the  resulting  mixture  is  not  unpleasant  to 
a  child.  If  given  sufficiently  early,  it  is  often  found  to  shorten,  in  a  re- 
markable manner,  the  course  of  the  inflammation,  and  prevent  suppuration. 
The  old-fashioned  treatment  by  salines,  with  moderate  doses  of  antimonial 
wine,  following  the  indispensable  purge,  finds  favour  with  many  practition- 
ers, and  is  no  doubt  often  very  successful.  Attention  to  the  bowels,  in- 
deed, must  never  be  neglected.  A  good  dose  of  calomel,  or  gray  powder, 
withcolocynthor  jalapine,  renders  the  after-course  of  the  disease  much  less 
harassing,  and,  if  all  irritation  of  the  thi'oat  is  avoided,  greatly  helps  the 
patient  along  in  his  path  to  recovery. 

Astringent  gargles  can  only  be  allowed  in  the  early  stage  of  the  disease. 
A  solution  of  alum  (twenty  grains  to  the  ounce)  may  be  used  in  this  way, 
but  is  only  admissible  if  the  febrile  action  is  mild,  and  if  the  case  is  seen 
within  the  first  twenty-four  hours.  At  a  later  period,  ordinary  astringent 
ai^plications  often  do  much  more  harm  than  good.  There  is,  however,  an 
exception  to  this  rule,  for  brushing  the  sxu'face  of  the  inflamed  tonsils 
with  the  pure  solution  of  the  subacetate  of  lead  is  often  attended  vnth  sur- 
prising relief  to  the  discomfort.  This  application  may  be  used  once  in  the 
day,  whatever  be  the  period  of  the  illness.  Another  apphcation  which  is 
often  of  service  is  the  bi-carbonate  of  soda,  applied  in  the  powder.  An  or- 
dinary throat  brush,  well  charged  with  the  powder,  may  be  used  to  convey 
the  latter  to  the  tonsil. 

Directly  signs  of  suppuration  are  noticed,  the  child  should  be  made  to  in- 
hale the  steam  of  hot  water,  and  hot  poultices  should  be  sedulously  ajDplied 
to  the  throat.  If  old  enough,  the  child  should  be  directed  to  gargle  fre- 
quently with  warm  water,  to  wliich,  if  there  be  any  foetor,  a  little  Condy's 
fluid  has  been  added.  If  necessary,  the  matter  when  it  forms  can  be  let 
out  by  a  touch  of  the  lancet,  but  in  most  cases  it  will  be  safe  to  aUow  it  to 
find  its  own  way  to  the  surface.  Still,  if  signs  of  dyspnoea  are  noticed, 
or  the  swelling  is  yery  large,  operative  interference  is  advisable.  After  the 
abscess  has  been  evacuated,  quinine  should  be  given  in  full  doses. 

The  diet  must  consist  at  first  of  milk  and  broth.  AVhen  the  difficulty 
of  swallowing  becomes  great,  strong  meat  essence  should  be  given,  and  the 
strength  may  be  supported,  if  the  child  appear  very  weak,  by  the  brandy- 
and-egg  mixture,  or  port  wine.  In  cases  of  the  non-sujDpurative  form  of 
the  disease,  where,  although  the  depr^sion  is  great,  febrile  action  is  mod- 
erate, and  the  inflammation  is  accompanied  by  shallow  ulcers  on  the  tongue 
and  cheeks,  chlorate  of  potash  is  very  useful,  and  may  be  given  in  doses  of 
five  to  ten  grains  every  tln-ee  or  four  hours.  These  cases  also  are  greatly 
benefited  by  purgation,  and  Epsom  salts  with  quinine  form  a  good  combi- 
nation. A  child  of  twelve  years  of  age  will  take  well  two  grains  of  quinine, 
with  half  a  drachm  of  sulphate  of  magnesia,  and  five  drops  of  dilute  sul- 
phuric acid,  every  six  hours.  This  treatment  cleans  the  loaded  tongue,  and 
improves  all  the  symptoms  with  remarkable  quickness.  In  young  children, 
too,  a  glass  of  port  wine,  given  quite  at  the  beginning  of  the  attack,  seems 
often  to  have  the  power  of  preventing  any  further  development  of  the  com- 
plaint. 

In  the  chronic  form  of  tonsillar  enlargement,  it  is  of  extreme  importance 
to  improve  the  general  nutrition  of  the  child.  It  will  be  usually  found  on 
inquiry  that  he  suffers  from  rej^eated  attacks  of  gastric  derangement.  Our 
first  care  must  be  to  improve  the  condition  of  the  digestive  organs  by  the 
means  recommended  elsewhere  (see  Gastric  Catarrh).  A  broad  flannel  band- 
age, to  protect  the  stomach  from  chills,  is  here  of  extreme  importance'. 


590  DISEASE   IJN"   CHILDEEJSr. 

Usually,  when  the  gastric  mucous  membrane  has  been  restored  to  a  healthy 
state,  the  general  condition  of  the  child  improves,  although  the  size  of  the 
tonsils  has  undergone  no  diminution.  Cod-liver  oil  and  iron  wine,  or  qui- 
nine and  tonics  generally,  may  be  given  to  hasten  the  return  of  flesh  and 
strength.  A  little  alcohol,  in  the  form  of  light  claret,  is  very  useful  in  these 
cases.  As  special  internal  treatment  of  the  swollen  tonsils,  Mr.  Lennox 
Browne  speaks  highly  of  the  influence  of  a  combination  of  sulphide  of  cal- 
cium and  iodoform  (half  a  grain  of  each),  given  three  times  a  day,  in  redu- 
cing the  size  of  the  glands. 

Of  local  measures,  no  doubt  the  best  and  most  effective'  proceeding  is 
excision.  The  tonsils  having  been  removed,  the  tendency  to  catarrh  in  a 
great  measure  subsides  ;  the  digestion  improves  ;  the  child  begins  to  regain 
flesh  and  colour,  and  the  congested  state  of  the  mucous  membrane,  which 
had  been  the  source  of  so  much  discomfort  and  inconvenience,  is  at  once 
relieved.  The  ojaeration  is  a  by  no  means  painful  one,  and  is  followed  by 
such  immediate  improvement  that  it  should  be  recommended  in  every 
case.  Often,  however,  the  suggestion  is  not  approved  of  by  the  j)arents, 
and  other  means  of  reducing  the  size  of  the  glands  will  have  to  be  resorted 
to.  The  tonsils  may  be  j)ainted  twice  a  day  with  a  mixture  of  equal  parts 
of  tinct.  iodi  and  Hq.  potassae  ;  or  once  a  day  with  the  pure  tinct.  iodi. 
Powdered  alum  may  be  apphed  according  to  Quinart's  method,  rubbing  it 
into  the  gland  vigorously  with  the  finger  ;  or  the  throat  may  be  brushed 
twice  a  day  with  glycerine  of  tannin.  These  appHcations  are,  however,  of 
doubtful  efficacy.  I  have  used  them  myself,  and  seen  them  employed  by 
others,  but  even  if  the  size  of  the  glands  is  reduced  for  a  time  by  such 
means,  the  improvement  is  seldom  a  permanent  one.  Dr.  Morell  Macken- 
zie speaks  highly  of  a  paste  composed  of  equal  parts  of  caustic  lime  and 
soda  with  spirit.  This  is  to  be  applied  to  different  joarts  of  the  swollen 
surface  once  or  twice  a  week.  Other  caustics,  such  as  nitrate  of  silver, 
Vienna  paste,  and  chloride  of  zinc  (in  the  stick)  have  been  used,  and  the 
galvano-cautery  has  also  been  employed.  By  the  use  of.  these  agents,  small 
portions  of  the  enlarged  and  toughened  glands  are  destroyed  on  each  ap- 
]olication  ;  but  the  size  of  the  tonsils  is  but  slowly  reduced  by  this  means 
— indeed,  the  patience  of  the  child's  relatives  is  usually  exhausted  before 
any  definite  results  have  been  obtained.  A  more  rapid  method  is  that 
recommended  by  Dr.  Gordon  Holmes.  A  thin  stick  of  nitrate  of  silver  is 
pressed  into  the  tonsillar  crypts,  and  worked  round  for  a  few  seconds. 
Small  sloughs  are  thus  formed,  which  are  soon  discharged.  The  process 
can  be  repeated  every  other  day,  and  by  this  means,  with  little  suffering  to 
the  child,  for  the  operation  is  followed  by  but  little  external  soreness  of 
the  throat,  the  size  of  the  glands  may  be  quickly  and  materially  reduced. 
Another  plan  is  to  inject  a  solution  of  ergotin  (  3  j.— jss.  to  ?  j.)  with  the 
hypodermic  syringe  into  the  enlarged  tonsil.  Three  to  five  drops  may  be 
slowly  introduced  into  the  gland  once  or  twice  a  week.  The  operation 
seems  to  cause  some  pain,  and  is  so  greatly  dreaded  by  the  child  that  it  is 
difficult  to  persevere  with  it  for  long  together.  I  have  never  seen  a  case 
where  the  glands  have  been  appreciably  diminished  by  this  means. 

French  authors  recommend  sulphurous  baths  as  efficacious  in  redu- 
cing the  size  of  the  glands,  but  I  cannot  speak  from  my  own  experience  of 
the  value  of  this  method  of  treatment. 


CHAPTEE  YII. 

EBTRO-PHAEYNGEAL  ABSCESS* 

Collections  of  matter  occasionally  form  in  tlie  loose  cellular  tissue  at 
the  back  of  tlie  pharynx.  The  disease  is  of  importance,  as  the  abscess,  by 
its  situation,  interferes  seriously  with  the  functions  of  respiration  and  deg- 
lutition, and  gives  rise  to  symptoms  which,  unless  referred  to  their  true 
origin,  may  be  a  source  of  considerable  perplexity. 

Ca fisa^ion.—Eetro-pharyngeal  abscess  is  more  common  in  childhood 
than  in  after  years,  and  dm'ing  the  first  twelve  months  than  at  a  later 
period  of  life.  In  eighty-nine  cases  collected  by  Gautier,  nearly  one-third 
of  the  patients  were  infants  under  a  year  old. 

Scrofulous  tendencies  appear  to  have  a  powerful  influence  in  favouring 
the  occurrence  of  the  disease.  In  the  subjects  of  this  diathesis,  the  abscess 
is  sometimes  foiuid  to  occur  as  a  sequel  of  one  of  the  acute  specific  diseases 
— of  scarlatina,  measles,  diphtheria,  or  erysipelas.  Caries  of  the  cervical 
vertebrae,  to  which  such  children  are  prone,  may  induce  it ;  and  it  may 
follow  tonsillitis,  ulcerations  about  the  mouth,  or  eczema  of  the  scalp  or 
back  of  the  neck.  In  many  cases,  however,  the  cause  of  the  malady  is 
obscure.  It  has  been  attributed  to  exposure  to  cold,  to  the  action  of  irri- 
tants, such  as  too  hot  Hquids,  and  to  injury  from  fish-bones,  pins,  and 
pointed  spiculse  of  bone  inadvertently  swallowed.  Indeed,  such  substances 
have  been  occasionally  discovered  in  the  contents  of  the  abscess. 

Morhid  Anatomy. — The  collections  of  matter  situated  behind  the  pos- 
terior wall  of  the  pharynx  vary  considerably  in  size.  Sometimes  they  are 
as  large  as  a  hen's  egg,  and  may  even  extend  for  a  considerable  distance 
upwards  and  downwards.  They  are  not  always  seated  in  the  middle  hne  ; 
indeed,  more  commonly,  perhaps,  they  are  placed  at  an  appreciable  distance 
to  one  side.  They  are  almost  invariably  single,  and  their  contents  consist 
of  purulent  and  cheesy  matter.  Sometimes  the  abscess  may  open  spon- 
taneously. In  other  cases  it  may  set  up  ulceration  in  a  large  vessel,  such 
as  the  carotid,  and  give  rise  to  fatal  haemorrhage.  Occasionally  it  has 
been  known  to  force  its  way  along  the  cellular  tissue  of  the  neck,  and  open 
into  the  mediastinum  or  the  pleural  cavity.  In  a  case  which  was  under 
the  care  of  my  colleague,  Mr.  Parker,  in  the  East  London  Children's  Hospi- 
tal— a  httle  boy  fifteen  months  old — the  abscess  formed  a  fluctuating  swel- 
ling, the  size  of  a  hen's  egg,  below  and  behind  the  angle  of  the  lower  jaw 
on  the  right  side.  There  was  also  a  soft,  cushiony  tumour  at  the  back  of 
the  pharynx.  After  the  abscess  had  been  opened  externally,  pressure  on 
the  pharyngeal  swelling  caused  pus  to  weU  up  through  the  wound. 

In  young  infants,  the  primary  seat  of  the  suppuration  appears  to  be  the 
lymphatic  glands  which  lie  along  the  posterior  wall  of  the  pharynx.  Kor- 
mann  states  that  with  his  finger  he  has  been  able  to  detect  enlargement 
of  these  glands  in  certain  cases  of  thrush,  ulcerative  stomatitis,  ozsena, 
etc.,  but  that  only  in  one  instance  has  he  known  the  inflammation  to  pro- 


692  DISEASE   IN"    CHILDREIT. 

ceed  to  suppuration.  Fleming,  too,  in  1850,  attributed  the  post-pharyn- 
geal  suppurations  to  inflammation  of  these  glands. 

Symptoms. — Unless  tlie  retro-pharyngeal  abscess  be  due  to  caries  of  the 
cervical  vertebrse,  the  case  seldom  comes  under  obsei-vation  until  some  im- 
pediment to  breathing  has  attracted  the  attention  of  the  mother.  The 
earlier  symptoms  are  usually  so  indefinite  that  they  excite  very  little  notice. 
If,  however,  the  purulent  collection  occurs  as  a  consequence  of  suppura- 
tion of  bone,  the  formation  of  the  abscess  is  preceded  by  symptoms  indica- 
cative  of  caries  of  the  vertebrse  of  the  neck.  These  sjTuptoms  have  been 
described  elsewhere  (see  page  178). 

Pain  or  difficulty  ^n  swallowing,  is  perhaps  the  first  symptom  observed. 
The  presence  of  the  pharyngeal  swelling  so  interferes  with  the  passage  of 
food  that  the  patient  may  have  the  greatest  difficulty  in  taking  nourish- 
ment. Liquids  can  often  be  swallowed,  but  soUd  matters  j)ass  only  with 
great  efibrt,  or  not  at  all.  Sometimes  the  obstacle  appears  to  be  complete. 
In  these  cases,  the  child,  if  an  infant,  sucks  eagerly  for  a  few  seconds,  and 
then  suddenly  throwing  back  his  head,  discharges  the  fluid  he  has  taken 
through  the  mouth  and  nose.  As  a  consequence  of  the  impediment,  serious 
interference  with  nutrition  invariably  follows,  and  the  child  loses  flesh  rap- 
idly. It  must  be  said,  however,  that  cases  are  sometimes  met  with  in  which 
no  difficulty  of  deglutition  is  present,  and  nutrition  appears  to  be  httle 
affected  by  the  presence  of  the  abscess. 

Dyspncea  is  another  symptom  which  is  usually  to  be  noticed,  and  often 
occurs  at  the  same  time  with  the  preceding.  There  appears  to  be  direct 
interference  with  the  entrance  of  air  into  the  lungs,  for  at  each  inspiration 
the  child  makes  a  curious  grating  or  whistling  sound,  and  at  the  same 
time  the  soft  parts  of  the  chest  sink  in,  and  the  epigastrium  is  retracted. 
The  dyspnoea  varies  in  degree.  It  is  subject  to  paroxysmal  exacerbations, 
but  in  the  intervals  the  respiration  is  far  from  tranquil.  When  the  child 
lies  down,  the  breathing  is  always  especially  difficult,  and  the  dyspnoea  is 
therefore  particularly  noticeable  at  night.  In  severe  cases,  the  jDatient  is 
obliged  to  raise  himself  in  bed  in  order  to  breathe  with  any  approach  to 
ease,  and  may  often  be  found  sitting  up  in  his  cot  with  his  legs  doubled 
beneath  his  body.  He  cries  fretfully  if  distui'bed,  or  invited  to  take  either 
food  or  drink,  and  will  not  willingly  make  any  attempt  to  swallow.  The 
dyspnoea  is  always  increased  when  pressure  is  made  externally  upon  the 
larynx. 

Cough  is  usually  present,  generally  dry  and  hard,  but  sometimes  par- 
oxysmal like  the  cough  of  pertussis.  The  voice  has  a  nasal  quality,  esj)e- 
cially  if  the  swelling  is  high  up  in  the  pharynx.  It  is  seldom  hoarse  if  the 
case  be  uncomplicated. 

Stiffness  of  the  neck  is  a  characteristic  symptom,  for  movement  of  the 
head  upon  the  shoulders  is  always  painful.  Consequently,  the  child  holds 
the  head  in  a  curiously  rigid  way,  sometimes  inclined  to  one  side  or  bent 
somewhat  backwards.  When  the  neck  is  examined,  it  is  often  found  to  be 
swollen.  Sometimes  the  depression  behind  the  angle  of  the  jaw  is  obliter- 
ated, and  Mondiere  points  to  this  as  a  characteristic  symptom.  Sometimes 
the  larynx  is  pushed  forwards,  or  forced  to  one  side  out  of  the  middle  line. 
Pressure  upon  the  neck  or  larynx  is  always  painful. 

On  inspecting  the  throat,  a  swelling  can  usually  be  seen  at  the  back  of 
the  pharynx,  protruding  from  beneath  the  soft  palate,  and  seeming  to 
touch  the  back  of  the  tongue.  The  mucous  membrane  may  not  be  altered 
in  colour,  and  often  there  is  no  redness  of  the  fauces.  On  touching  the 
swelling  with  the  finger,  it  is  usually  felt  to  be  soft  and  elastic  like  a  sac 


RETEO-PHAEYNGEAL   ABSCESS — SYMPTOMS,  593 

filled  with  fluid,  but  may  feel  firm  like  a  solid  growth.  The  finger  should 
be  passed  round  the  borders  of  the  prominence  so  as  to  define  its  limits. 
The  sweUing  does  not  always  come  into  view  when  the  mouth  is  opened ; 
for  not  only  is  it  often  obscured  by  more  or  less  frothy  mucus,  but  its  situ- 
ation may  be  such  that  it  is  not  readily  discovered.  If,  then,  we  suspect 
its  existence,  the  finger  should  be  rapidly  passed  upwards  to  the  back  of 
the  nose,  and  downwards  behind  the  glottis.  By  this  means  the  position 
of  the  abscess  can  usually  be  ascertained. 

The  above  symptoms  are  to  be  discovered  in  most  cases  of  the  disease  ; 
but  the  course  and  form  of  the  illness  vary  greatly  according  to  whether 
the  suppuration  is  an  acute  or  chronic  lesion. 

In  an  acute  suppuration  behind  the  pharynx  the  symptoms  are  very 
much  more  pressing  and  severe  than  in  the  more  chi'onic  form  of  retro- 
pharyngeal abscess.  The  disease  generally  begins  with  high  fever,  severe 
headache,  and  vomiting.  After  a  few  days,  stiffness  of  the  muscles  of  the 
neck  is  noticed,  with  a  peculiar  fixed  position  of  the  head,  and  there  may 
be  sweUing  of  the  neck  and  great  tenderness.  In  some  cases,  the  stiffness 
extends  to  the  muscles  of  the  jaw,  so  that  the  mouth  can  be  opened  only 
imperfectly.  At  the  same  time,  or  soon  afterwards,  there  is  difficulty  in 
swallowing,  and  the  breathing  is  laboured  and  stertorous.  If  the  child  is 
laid  down  these  symptoms  are  increased,  and  often  the  recumbent  position 
induces  a  state  of  somnolence  approaching  to  stupor.  If  the  symptoms  are 
not  relieved,  the  condition  of  the  child  becomes  more  and  more  distressed. 
His  face  is  swollen  and  livid,  and  the  jugular  veins  are  prominent.  He 
Hngers  for  a  few  days  in  this  state,  and  then  dies,  exhausted  from  inanition, 
or  suffocated  in  a  paroxysm  of  dyspnoea.  Death  is  often  preceded  by  a  se- 
ries of  convulsive  attacks. 

In  the  more  chronic  cases,  there  is  little  or  no  fever,  and  the  symptoms 
generally  are  much  less  urgent.  There  is,  however,  usually  a  noticeable 
interference  with  nutrition,  and  the  loss  of  flesh  is  considerable. 

The  duration  of  the  disease  varies  greatly.  In  some  cases  it  runs  a 
very  acute  course,  and  ends  fatally  in  a  fortnight  or  three  weeks.  This 
form  is  most  common  when  the  suppuration  occurs  as  a  sequel  of  fever. 
In  other  cases,  the  dyspnoea  and  dysphagia  continiie  for  months  before 
their  true  significance  is  realised. 

A  little  girl,  aged  three  years,  was  brought  to  me  at  the  hospital  for 
difficulty  of  breathing.  The  mother  stated  that  two  years  previously, 
while  teething,  the  child  had  suffered  from  an  eruption  on  the  head.  This 
had  been  quickly  followed  by  a  swelling  at  the  right  side  of  the  neck,, 
which,  after  growing  larger  for  two  months,  had  biu'st.  Very  shortly  af- 
terwards the  breathing  had  been  noticed  to  be  oppressed,  and  the  respi- 
ration had  begun  to  be  accompanied  by  a  peculiar  whistling  or  rattling 
noise.  This  symptom  had  continued  ever  since,  and  was  always  worse  at 
night.  The  child  was  said  to  sleep  very  heavily,  with  her  eyes  only 
partially  closed.  Sometimes  she  had  seemed  to  have  a  difficulty  in  swal- 
lowing. 

When  first  seen,  the  child  was  lying  asleep,  resting  on  the  right  side  of 
her  chest.  She  was  sweating  profusely  about  the  head  and  neck.  Her 
face  was  flushed,  and  the  eyes  were  onty  partially  closed.  The  mouth  was. 
open,  and  the  nares  were  motionless  in  respiration.  At  each  breath  the  in- 
tercostal spaces  sank  in  deeply,  and  the  epigastrium  was  depressed.  With 
each  inspiration  a  peculiar  grating  noise  was  heard,  which  seemed  to  pro- 
ceed from  the  throat.  The  expirations  were  less  noisy,  but  still  abnormal. 
The  glands  along  the  edge  of  the  sterno-mastoid,  and  those  below  the  jaw, 
38 


594  DISEASE  IN   CHILDREN", 

were  enlarged  and  painless,  and  tlie  larynx  and  trachea  seemed  pushed  out 
of  the  middle  line  to  the  left. 

On  inspecting  the  fauces,  a  swelling  about  the  size  of  a  plover's  egg  could 
be  seen  at  the  back  of  the  pharynx.  On  pressing  this  with  the  finger,  it 
felt  firm  like  a  solid  tumour. 

The  swelling  was  punctured  with  a  large  trocar  and  canula,  and  half 
an  ounce  of  thick  pus  was  evacuated.  After  the  operation  the  breathing 
became  quieter,  and  swallowing  was  effected  without  difficulty.  The  ab- 
scess continued  to  discharge  for  some  days  and  then  healed.  When  the 
child  left  the  hospital  she  seemed  well  in  health,  but  some  thickening  re- 
mained at  the  back  of  the  pharynx. 

In  this  case,  the  disease  had  lasted  for  two  years,  and  was  apparently 
the  consequence  of  slow  softening  of  a  cheesy  gland  at  the  back  of  the 
pharynx.  The  cervical  glands  were  also  enlarged  and  caseous  ;  and  from 
one  of  these,  seated  behind  the  angle  of  the  jaw,  a  quantity  of  cheesy  mat- 
ter was  scooped  out  by  my  colleague,  Mr.  Reeves. 

Whatever  be  the  length  of  its  course,  a  retro-pharyngeal  abscess,  if  un- 
recognised, generally  terminates  in  death.  As  has  been  before  remarked, 
the  child  usually  dies  suffocated  in  a  paroxysm  of  dyspnoea,  or  gradually 
wastes  away  from  starvation  and  exhaustion.  Even  spontaneous  bursting 
of  the  abscess  appears  to  be  attended  with  great  danger,  and  cases  are  re- 
ported in  which  suffocation  has  been  the  consequence  of  the  passage  of  the 
purulent  matter  into  the  trachea. 

Diagnosis. — Amongst  the  various  causes  of  dyspnoea  in  the  child,  it  must 
not  be  forgotten  that  retro-pharyngeal  abscess  is  one  ;  and  in  every  case 
where  the  breathing  is  difficult  and  stertorous,  the  pharynx  should  be  ex- 
amined as  a  matter  of  routine.  If  this  be  done,  the  disease  is  not  likely 
to  be  overlooked,  for  a  finger  passed  to  the  back  of  the  pharynx  at  once 
detects  the  presence  of  the  abscess.  Moreover,  information  may  be  some- 
times gained  from  mere  inspection  of  the  neck.  Any  unusual  prominence  of 
the  trachea,  or  displacement  of  that  tube  to  the  right  or  left  of  the  middle 
line,  suggests  an  extra-laryngeal  cause  for  the  dyspnoea.  So,  also,  if  we 
find  the  child  sitting  up  in  bed  and  refusing  to  lie  down  ;  or  if  laid  down, 
starting  up  again  in  an  access  of  suffocation,  we  should  suspect  external 
pressure  upon  the  larynx.  The  more  characteristic  symptoms  are  :  Stiff- 
ness and  swelling  of  the  neck,  and  difficulty  of  swallowing,  combined  with 
orthopnoea  and  stridulous  breathing.  The  most  characteristic  sign  is  a 
swelling  at  the  back  of  the  pharynx,  which  is  not,  indeed,  always  to  be  seen, 
but  can  invariably  be  felt  by  digital  exploration. 

The  disease  is  more  hkely  to  be  misapprehended  in  the  acute  than  in 
the  chronic  form  ;  for  the  violence  of  the  symptoms,  the  lividity  of  the 
face,  the  urgency  of  the  dyspnoea,  and  the  stertorous  character  of  the  breath- 
ing, suggest  the  presence  of  membranous  croup.  But  in  that  disease,  stertor 
is  present  from  the  beginning  ;  the  dyspnoea  is  not  increased  by  pressure 
made  upon  the  trachea,  and  is  reheved  when  the  head  is  low  ;  the  voice 
rapidly  becomes  hoarse  and  then  whispering  ;  and  unless  the  pharynx  be 
the  seat  of  false  membrane,  there  is  no  difficulty  in  swallowing. 

CEdema  of  the  glottis  also  presents  many  points  of  similarity  wdth 
abscess  of  the  pharynx  ;  but  in  the  former  case  the  stridor  is  only  marked 
in  inspiration,  the  expiration  being  noiseless  ;  and  when  the  finger  is 
passed  into  the  throat  it  detects  no  tumour,  but  can  feel  the  thickened 
epiglottis  and  the  swollen  ary-epiglottidean  folds.  Still,  the  tw^o  diseases 
may  be  present  together  ;  but  if  a  tumour  can  be  felt  at  the  back  of  the  phar- 
ynx on  digital  examination,  the  nature  of  the  disease  cannot  be  doubtful. 


RETRO -PHAEYNGEAL  ABSCESS — PROGNOSIS — TREATMENT.      595 

Prognosis. — If  the  abscess  is  detected  in  time,  the  prognosis  is  favoura- 
He.  When  death  occui'S  in  this  disease,  it  is  usually  in  cases  where  the 
cause  of  the  symptoms  has  been  overlooked,  and  no  attempt  has  been 
made  to  relieve  the  child  by  the  only  means  which  are  likely  to  prove  ef- 
fectual. The  worst  cases  are  those  in  which  the  abscess  is  the  consequence 
of  careous  disease  of  bone  ;  but  even  these  may  end  in  recovery  if  the 
matter  be  evacuated  before  the  child  has  become  exhausted. 

Treatment. — In  the  treatment  of  retro-pharyngeal  abscess,  no  time  should 
be  lost.  Directly  the  tumour  is  recognised,  it  should  be  opened,  whether 
fluctuation  be  present  or  not.  In  order  to  avoid  any  risk  of  penetration  of 
the  pus  into  the  larynx,  it  is  perhajDS  safer  to  use  a  large  trocar  and  can- 
ula  ;  but  the  abscess  may  be  opened  with  a  knife  without  danger  if  care 
be  taken  to  bend  the  child's  head  promptly  forwards  when  the  incision 
is  made.  The  bistoury  should  be  guarded  to  within  half  an  inch  of  its 
point  by  winding  adhesive  plaster  round  the  blade.  The  opening  must  be 
made  as  near  the  middle  line  as  possible  ;  and  the  instrument  may  be 
pushed  boldly  forwards,  for  the  pus  often  lies  at  some  distance  from  the 
surface.  If  a  trocar  be  used,  the  abscess  sometimes  refills,  and  may  require 
a  second  puncture  after  a  few  days. 

The  general  health  of  the  child  must  be  attended  to.  Good  diet  and  a 
certain  quantity  of  stimulant  should  be  allowed  ;  and  he  may  take  quinine 
and  cod-liver  oil.  When  convalescentj  the  patient  will  be  benefited  by  a 
visit  to  the  seaside. 


Part  9. 
DISEASES  OF  THE  DIGESTIVE  ORGANS. 


CHAPTER  I. 

INFAJSTTILE  ATEOPHY. 


ibrFANTiLE  atrophy,  or  the  slow  wasting  which  is  a  familiar  symptom  in 
hand-fed  babies,  is  one  of  the  commonest  causes  of  death  in  early  infancy. 
The  child  ceases  to  digest  liis  food — possibly  he  has  never  begun  to  do  so  ; 
gTadually  dwindles  away,  and  after  a  longer  or  shorter  period,  dies  with 
all  the  symptoms  of  starvation.  This  condition,  which,  under  the  name  of 
"marasmus,"  finds  a  large  place  in  the  mortahty  returns  of  all  countries, 
is  a  perfectly  culpable  complaint,  and  may  be  arrested  at  almost  any  stage 
by  the  exercise  of  judgment  and  care  in  the  feeding  and  general  manage- 
ment of  the  infant. 

Causation. — Infantile  atrophy  is  the  consequence  of  insufficient  nourish- 
ment. The  child  wastes  because  he  is  starved.  But  it  is  not  to  actual 
lack  of  feeding  that  the  starvation  is  usually  to  be  ascribed.  A  baby 
fed  fi'om  a  breast  which  secretes  milk  poor  in  quality  and  insufficient  for 
the  child's  suppori,  will,  of  course,  grow  slowly  thinner  ;  but  an  infant  sup- 
phed  largely  with  farinaceous  compounds  from  which  his  feeble  digestive 
organs  fail  to  derive  even  a  minimum  of  nourishment,  will  waste  with  start- 
ling rapidity.  Starvation  is  then  a  relative  term.  The  tissues  may  be 
stai-ved,  although  the  stomach  is  regularly'  filled.  In  every  case,  the  nutri- 
tion of  the  infant  is  dependent  upon  his  power  of  extracting  a  sufficiency 
of  nourishment  from  his  so-called  "food."  It  may  seem  imnecessaiy  to 
insist  upon  so  self-evident  a  matter  ;  but  in  practice  it  is  common  to  find  a 
diet  persisted  with  which  the  infant's  stomach  rejects,  or  his  tissues  fail  to 
assimilate.  Many  a  baby's  life  is  sacrificed  through  the  inability  of  those 
about  the  child  to  understand  that  feeding  and  nourishing  are  not  quite 
the  same  thing. 

For  efficient  nourishment,  four  classes  of  substance  are  indispensable, 
viz.,  albuminates,  hydro-carbonates,  fats,  and  salts.  It  is  further  necessary 
that  these  should  be  presented  to  the  child  in  such  a  form  that  they  can  be 
digested  with  ease.  The  most  perfect  food  for  infants — the  only  one,  in 
fact,  which  can  be  rehed  upon  in  itself  to  furnish  all  these  requirements — is 
milk.     Milk  contains  nitrogenous  matter  in  the  curd,  fat  in  the  cream,  be- 


INFANTILE   ATROPHY — CAUSATION. 


597 


sides  sugar  and  the  salts  wliich  are  essential  to  perfect  nutiition.  In  the 
imlk  of  the  mother  or  of  a  good  ntu'se  the  new-born  infant  finds  these  ele- 
ments combined  in  exactly  the  proportions  best  adapted  to  supply  all  the 
wants  of  his  system.  In  the  milk  of  animals,  the  proportions  deviate  more 
or  less  widely  fi'om  the  human  standard.  Cow's  milk,  especially,  contains 
a  larger  proportion  of  cui'd  and  cream  than  is  found  in  human  milk,  but 
less  sugar  ;  and  although  to  an  exceptionally  sturdy  infant  this  difference 
ma}^  be  immaterial,  for  a  child  of  ordinaiy  powers  it  will  be  necessary,  by 
suitable  preparation,  to  biing  the  milk  into  closer  resemblance  with  the 
natural  diet  of  which  he  has  been  deprived. 

The  chief  obstacle  to  the  digestion  of  cow's  milk  by  young  babies  is  not, 
however,  the  mere  difference  in  the  proportion  of  the  several  constituents. 
Were  this  so,  dilution  with  water  and  the  addition  of  sugar  of  milk  w^ould 
be  sufficient  to  perfect  the  resemblance  between  the  two  fluids.  A  more 
important  difference  is  the  denseness  of  the  clot  formed  by  the  curd  of 
cow's  milk.  Ample  dilution  with  water  does  not  affect  this  property.  Un- 
der the  action  of  the  gastric  jviice,  the  particles  of  casein  stiU  run  together 
into  a  soUd,  compact  lump.  This  is  not  the  case  with  milk  from  the  breast. 
Human  milk  forms  a  light,  loose  flocculent  clot,  which  is  readily  disinte- 
grated and  digested  in  the  stomach.  The  difficulty  which  even  the  strong- 
est children  find  in  digesting  cow's  milk,  is  shown  by  the  masses  of  hard 
curd  which  a  child  fed  exclusively  upon  this  diet  passes  daily  from  the 
b)Owels.  This  difference  between  the  two  milks  is  answerable  for  much  of  the 
trouble  and  disappointment  experienced  in  bringing  up  infants  by  hand. 
But  it  is  not  merely  new^-born  infants  for  whom  a  diet  of  cow's  milk  is  inap- 
propriate. Gastric  and  intestinal  disorders  often  date  from  the  time  of 
weaning  ;  and  this  is  partly  the  consequence  of  an  abruj^t  change  from 
hTiman  to  cow's  milk  in  cases  where  little  or  no  care  is  taken  to  make  the 
new  diet  a  digestible  one.  The  heavy  curd  of  cow's  milk  is  often  difficult 
of  digestion,  even  by  children  of  ten  or  twelve  months  old,  if  they  have  been 
accustomed  only  to  the  breast ;  and  unless  measures  are  adopted  to  hinder 
the  firm  clotting  of  the  casein,  serious  dangers  may  arise. 

The  difference  in  the  constitution  of  the  mUk  of  the  woman,  the  cow, 
the  ass,  and  the  goat,  are  seen  in  the  following  table  prepared  by  MM.  Ver- 
nois  and  Becquerel : — 


Sp.  Gr.    j    Water. 

Solids. 

Sugar. 

Casein 
and  Ex- 
tractives. 

Butter. 

Salts. 

"Woman 

Cow 

1032.67    889.08 
1033.38    864.06 
1034.57    890.12 
1033.53    844.90 

110.92 
135.94 
107.88 
153.10 

43.64 
38.03 
50.46 
86.91 

39.24 
55.15 
35.65 
55.14 

'  26.66 
36.14 
18.53 
56.87 

1.88 
6.64 

Ass 

5.24 

Goat 

6.18 

The  milk  of  the  ass  approximates  most  nearly  in  composition  to  that 
of  the  human  breast,  and  is  much  more  digestible  than  the  milk  of  the 
cow.  The  goat  yields  a  milk  which  chemically  resembles  very  closely  that 
of  the  cow,  but  in  practice  it  is  found  to  be  far  more  digestible  by  the 
child.  This  is  no  doubt  due  to  the  looser  clot  formed  in  the  stomach  by 
its  coagulated  curd. 

As  cow's  milk  diluted  with  water  is  considerably  less  digestible  than  the 


598  DISEASE   IlSr   CHILDKElSr. 

milk  of  the  human  breast,  it  is  not  surprising  that  a  weakly  child  should 
fail  to  derive  sufficient  noiu'ishment  from  such  a  diet.  If  he  be  fed  with 
large  quantities  of  farinaceous  food,  his  difficulties  are  still  further  in- 
creased. The  new-born  infant  has  only  a  feeble  capacity  for  digesting 
starch.  His  salivary  secretion  is  excessively  scanty,  and  his  pancreas  can 
scarcely  be  said  to  furnish  any  secretion  at  all.  According  to  the  experi- 
ments of  Korowin,  of  St.  Petersbiu-g,  it  is  not  until  the  end  of  the  third 
month  after  birth  that  the  pancreatic  fluid  is  found  to  have  any  appreciable 
action  upon  starch.  The  two  secretions  upon  which  the  digestion  of  starch 
chiefly  depends  are  therefore  almost  completely  absent  in  early  infancy.  Yet 
it  is  to  a  being  quite  unprepared  by  nature  for  this  diet  that  farinaceous 
substances  under  the  misleading  name  of  "Infants'  Foods"  are  so  univer- 
sally given.  Many  babies  are  fed  with  them  exclusively  from  their  birth  ; 
others  take  them  in  large  quantities  as  an  addition  to  the  breast-milk.  In 
either  case,  the  meal  is  in  great  part  undigested,  and  gives  rise  to  much  flatu- 
lence and  pain  in  its  passage  along  the  alimentary  canal.  It  must  be  borne 
in  mind  that  the  effect  of  an  indigestible  diet  is  not  merely  the  withhold- 
ing of  nourishment.  To  the  weakness  of  starvation  or  semi-starvation 
must  be  joined  the  additional  weakness  induced  b}^  catarrh  of  mucous 
membrane  fi'om  the  constant  passage  along  the  bowel  of  undigested  and 
fermenting  food.  The  ii-ritation  thus  set  up  gives  rise  to  repeated  attacks 
of  vomiting  and  diarrhoea ;  and  even  between  the  attacks,  although  the 
irritation  is  for  the  time  less  severe,  the  child  is  restless  and  uncomfort- 
able, crying  and  whining,  and  unable  to  sleep  from  the  colicky  pains  in  his 
beEy.  Unfortunately  for  the  infant,  this  consequence  of  his  unsuitable 
diet  is  often  mistaken  by  ignorant  or  too  anxious  attendants  for  signs  of 
hunger  ;  and  while  the  poor  sufferer  is  still  labouring  to  dispose  of  his  last 
meal,  another  supply  of  food,  which  his  craving  forces  him  eagerly  to  swal- 
low, increases  his  difficulty  and  discomfort.  It  is  not,  then,  surprising  that 
the  infant,  extracting  no  nourishment  from  his  frequent  meals,  grows  daily 
thinner  and  more  feeble,  and  sinks  at  last,  worn  out  by  purging,  pain,  and 
want  of  sleep. 

The  sj'mptoms  of  indigestion  which  always  precede  the  more  pro- 
nounced signs  of  infantile  atrophy,  sometimes  come  on  quite  suddenh^  and 
unexpectedly  in  an  infant  who  has  been  fed  with  judgment,  and  has  at 
first  appeared  to  thrive.  The  faUing  off  is  due,  in  the  majority  of  cases,  to 
some  casual  derangement  of  the  stomach  and  bowels  which  induces  an 
acid  change  in  his  food.  The  child  consequently  ceases  to  be  able  to  di- 
gest his  milk.  The  fluid  undergoes  fermentation  in  his  stomach,  and  gen- 
erates an  acid  which  irritates  the  delicate  mucous  membrane  and  increases 
the  disturbance  of  the  digestive  organs.  Severe  symptoms  are  often  the 
consequence  of  this  indigestion,  so  that,  unless  timely  measures  are  taken 
to  avert  the  danger,  the  child's  life  may  be  sacrificed.  An  attack  of  gas- 
tric catarrh,  induced  by  a  slight  chill,  is  the  commonest  cause  of  this  sud- 
den indigestion  ;  but  sometimes  the  derangement  is  the  result  of  over- 
feeding, the  child's  meals  being  too  large  or  too  frequently  repeated  ;  or, 
again,  the  feeding  apparatus  may  have  been  neglected,  so  that  milk  put 
into  a  dirty,  sour  bottle,  has  begun  to  ferment  before  the  child  swallows  it. 
In  warm  weather,  milk  soon  becomes  sour,  even  in  clean  vessels  ;  indeed, 
if  some  time  have  elapsed  since  the  milk  was  drawn  fxom  the  udder,  it 
may  be  delivered  at  the  house  in  a  slightly  acid  state,  although  ajapearing 
to  be  perfectly  fresh  to  the  eye,  the  smell,  and  even  to  the  taste. 

There  is  one  other  cause  of  infantile  indigestion  and  bowel  complaint 
which  should  be  mentioned,  as  the  fault  is  a  common  one.     In  households 


INFANTILE   ATROPHY — CAUSATION.  599 

where  it  is  tlie  custom  to  prepare  for  the  infant  in  the  morning  the  whole 
day's  supply  of  food,  an  acid  change  in  the  mixture  almost  invariably  takes 
place,  so  that  in  the  afternoon  or  evening  the  food  is  no  longer  fit  for  the 
child's  consumption.  The  change  may  occur  without  necessarily  pi'odu- 
cing  any  alteration  appreciable  by  the  senses.  Test  paper  will,  however, 
show  acidity,  and  the  microscope  will  probably  reveal  bacteria  in  active 
motion. 

A  derangement  of  the  stomach  and  bowels,  occurring  suddenly  from 
any  of  these  causes,  not  only  interferes  with  the  infant's  nutrition  for  the 
time,  but  often  produces  much  more  serious  consequences.  It  may  set  up 
a  disorder  in  the  digestive  system  which  is  never  afterwards  recovered 
from,  and  start  a  process  of  gradual  wasting  which  ends  only  with  the 
death  of  the  child.  It  is,  indeed,  in  incidents  of  this  kind  that  the  chief 
danger  of  artificial  feeding  consists  ;  for  a  diet  arranged  originally  with 
care  and  judgment  ceases  to  be  appropriate  in  these  altered  conditions. 
An  immediate  change  is  imperative  if  the  derangement  is  to  be  remedied ; 
and  for  some  time  afterwards  a  careful  watch  must  be  kept  over  the  in- 
fant's digestion,  lest  the  disorder  return. 

Infantile  atrophy  is  seldom  seen  to  any  serious  extent  in  infants  at  the 
breast,  but  sometimes  a  certain  degree  of  malnutrition  is  observable  in 
babies  who  take  no  other  food.  This  may  result  from  different  causes. 
An  infant  may  be  consigned  to  a  wet-nurse  whose  own  child  is  much  older 
than  her  adopted  suckling.  It  is  well-known  that,  as  time  passes,  human 
milk  becomes  proportionately  richer  in  curd  and  cream.  An  infant,  new- 
born, and  with  naturally  feeble  digestive  power,  put  to  the  breast  at  a  late 
period  of  lactation,  may  consequently  fafl.  to  thrive ;  or  may  even  suffer 
from  indigestion  and  bowel  complaint  through  the  richness  of  the  milk. 
Again,  in  some  women,  the  milk,  although  abundant,  is  of  poor  quality,  and 
insufficient  for  the  support  of  a  strong  baby,  so  that  the  child  soon  shows 
signs  of  deficient  nutrition.  Human  milk  is  also  affected  by  dietetic  and 
emotional  causes,  and  the  secretion  is  apt  to  be  influenced  by  the  general 
state  of  health.  There  are  many  reasons,  therefore,  why  a  child,  even  while 
at  the  breast,  should  be  subject  to  casual  derangements.  Still,  these  are 
usually  trifling,  and  seldom  produce  any  serious  effect  upon  his  nutrition. 

It  sometimes  happens  that  a  mother's  milk  is  not  well  suited  for  the 
nourishment  of  her  offspring,  even  in  cases  where  the  secretion  is  copious, 
the  child  a  sturdy  boy,  and  the  health  of  the  mother  in  every  way  satisfac- 
tory. Some  years  ago  I  was  asked  by  a  gentleman  to  go  and  see  his  child 
— -a  little  boy  of  seven  months  of  age.  I  found  that  the  child  had  been 
suffering  for  some  weeks  from  severe  abdominal  pains.  He  was  excessive- 
ly peevish  and  fretful,  and  at  night  would  wake  up  with  a  scream,  and  twist 
about  his  body  under  the  influence  of  severe  griping  pain.  His  bowels 
were  very  confined,  and  the  motions  consisted  almost  entirely  of  curd.  He 
was  taking  nothing  but  the  breast.  Aperients  had  been  found  to  relieve 
the  child  for  a  time,  but  the  symptoms  always  returned  when  the  effect  of 
the  purgative  had  passed  away.  Whenever  the  breast  was  stopped  for  a 
few  days,  he  immediately  improved,  but  relapsed  as  soon  as  suckling  was 
resumed.  The  child  had  lost  flesh,  and  was  evidently  suffering  from  his 
inability  to  digest  the  curd  of  his  mother's  milk.  It  was  therefore  a  matter 
of  great  importance  to  enable  him  to  do  so  ;  otherwise  he  would  have  to  be 
weaned,  and  fed  in  a  different  way.  The  mother  had  herself,  by  taking  salines 
and  other  medicines,  and  by  making  many  modifications  in  her  diet  under 
medical  advice,  endeavoured  to  alter  the  quality  of  her  milk,  but  without 
success. 


600  DISEASE  IN   CHILDEEN. 

Several  methods  of  remedying  the  e\il  were  tried.  The  intervals  between 
the  times  of  sucMing  were  increased,  so  as  to  give  a  longer  period  for  di- 
gestion ;  but  this  change  had  no  effect  whatever.  Alternate  meals  of  barley- 
water  were  then  given  from  a  feeding-bottle.  By  this  means,  the  quantity 
of  milk  taken  by  the  child  in  the  course  of  the  day  was  diminished,  and 
the  interval  between  the  times  of  suckling  was  still  further  increased.  No 
improvement,  however,  followed  the  alteration.  The  griping  pains  still 
continued,  and  the  constant  fretfulness  of  the  child  was  most  distressing 
to  the  mother.  The  plan  was  at  last  adopted  of  giving  the  child  barley- 
water  from  a  bottle  immediately  before  he  took  the  breast,  in  the  hope  that 
by  this  means  the  milk  might  be  diluted  directly  it  reached  the  stomach. 
This  method  succeeded  perfectly,  and  the  child  had  no  further  unpleasant 
symptoms. 

In  this  instance,  the  infant's  stomach  was  in  a  perfectly  healthy  state.  The 
fault  lay  in  the  mother's  milk,  which  was  too  heavy  for  the  child's  powers  of 
digestion.  In  the  large  majority  of  cases  of  indigestion  in.  infants  reared 
at  the  breast,  the  fault  is  in  the  digestive  organs  of  the  child,  an  attack  of 
gastric  catarrh  having  rendered  him  for  the  time  incapable  of  digesting  his 
mother's  milk.  In  these  cases,  the  indigestion  is  a  temporary  failing,  and 
is  easily  remedied  by  suitable  treatment.  Without  judicious  management, 
the  derangement  may  be  prolonged  indefinitely  ;  and  it  not  unfrequently 
happens  that  the  mother  is  directed  to  wean  her  baby  under  the  mistaken 
notion  that  her  milk  is  tmfit  for  its  support. 

31orbid  Anatomy. — In  cases  of  death  from  infantile  atrojjhy,  the  tissues 
are  found  excessively  wasted,  and  there  is  complete  absence  of  adipose  tissue 
from  the  body.  The  general  pathological  appearances  are  such  as  have 
been  already  described  as  common  to  cases  of  thi'ush  (see  page  572). 

Symptoms. — When  a  child  at  the  breast  depends  for  his  support  upon 
a  scanty  supply  of  poor  mUk,  he  suffers  no  jDain,  but  wastes  persistently. 
The  infant  is  peevish  from  hunger,  and  at  times  cries  violently.  For  the 
same  reason  he  sleeps  httle,  and  at  night  is  very  troublesome.  In  the  day- 
time he  often  hes  quietly  sucking  his  fingers  until  they  are  raw.  His  fon- 
tanelle  is  level  or  depressed  ;  his  skin  is  moist ;  his  bowels  are  confined ; 
the  motions  scanty  and  often  almost  solid.  He  soon  becomes  pale  and 
flabby,  and  does  not  gTow.  If  the  milk,  although  poor  and  watery,  is  abun- 
dant, the  child  frequently  requires  the  breast.  He  sleeps  much,  and  often  is 
found  asleep  with  the  nipple  still  in  his  mouth.  This,  indeed,  is  a  common 
sign  of  watery  milk.  If  noticed  in  a  child  who  is  not  thriving,  but  in  whom 
no  positive  derangement  can  be  discovered,  measures  should  at  once  be 
taken  to  change  the  nurse,  or  sujDplement  the  breast-milk  by  a  suitable  diet. 

In  hand-fed  babies,  infantile  atrophy  is  often  seen  m  its  most  extreme 
degTee.  A  child  fed  with  unsuitable  food  is  not  only  starved,  but  is  kept 
in  a  state  of  continual  distress  ;  so  that  we  find  persistent  wasting  com- 
bined with  symptoms  more  or  less  striking  of  gastric  and  intestinal  dis- 
turbance. 

The  loss  of  flesh  is  noticed  from  the  very  beginning.  Its  rapidity  de- 
pends partly  upon  the  kind  of  food  chosen  ;  partly  ujDon  the  natural 
strength  of  the  child,  and  his  capacity  for  extracting  nourishment  from 
his  unwholesome  diet.  A  puny  infant,  fed  with  large  quantities  of  arrow- 
root, or  other  equally  inappropriate  food,  wastes  very  rapidly,  and  at  the 
end  of  two  or  three  months,  if  he  lives  so  long,  may  actually  appear  to 
have  made  no  advance  in  size  or  in  strength  since  his  birth.  Such  an  in- 
fant IB  pale  and  miserably  thin,  his  skin  is  dry,  and  has  a  faint  yellow  tint ; 
his  eyes  are  hollow ;  his  cheek-bones  project ;  his  lips  are  livid,  and  their 


INFANTILE   ATKOPHY — SYMPTOMS.  601 

sKghtest  movement  shows  a  deep  furrow  encircling  the  corners  of  the 
mouth ;  his  expression  is  uneasy  and  languid ;  his  feet  and  hands  are  habit- 
ually cold,  and  he  whines  and  cries  fretfully  for  hours  together.  These 
chndi'en  often  have  a  ravenous  appetite  for  food,  and  wiU  swallow  greedily 
whatever  is  offered  to  them.  The  meal,  however,  produces  merely  a  tem- 
porary rehef,  and  as  soon  as  the  griping  pains  to  which  it  gives  rise  make 
themselves  felt,  the  child's  waihngs  are  renewed.  The  abdominal  pains 
excited  by  the  indigestible  natui-e  of  his  food  are  often  very  severe.  The 
infant  may  become  quite  stiff  and  rigid  from  his  sufferiag,  and  scream 
with  white,  drawn  face  and  staring  eyes  until  exhausted.  Sometimes  the 
gripiag  gives  rise  to  a  convulsive  fit,  although  this  is  rare,  but  the  irrita- 
tion of  the  bowels,  and  acidity,  not  unfrequently  excite  signs  of  nervous 
irritation  ;  we  notice  sudden  starts  and  twitches,  a  slight  squint,  a  pecu- 
har  rotation  of  the  eyeball  upwards,  and  contractions  of  the  fingers  and 
toes. 

Eruptions  on  the  skia,  such  as  strophulus  and  urticaria,  are  common  ; 
and  in  the  later  stage  of  the  illness,  ajDhthse  or  thrush  may  appear  in  the 
mouth. 

The  state  of  the  bowels  varies.  It  is  probably  dependent  upon  the  de- 
gree to  which  the  mucous  membrane  is  mitated  by  the  child's  unsuitable 
diet.  If  this  mitation  be  only  moderate,  the  bowels  are  usually  confined. 
The  infant  is  restless,  and  may  be  noticed  to  be  feverish  at  night.  His 
tongue  is  coated  with  a  thick  white  fur.  He  is  evidently  in  a  state  of 
great  discomfort,  for  his  temper  is  peevish  and  fretful,  his  movements  are 
uneasy  and  jerking,  and  he  occasionally  breaks  out  into  piercing  cries, 
drawing  up  his  knees  and  twisting  about  his  body  under  the  influence  of 
abdominal  pain.  At  night  the  griping  is  especially  violent ;  the  child 
scarcely  sleeps  at  aU,  or  if  he  be  quiet  for  a  moment  in  Tineasy  sleep,  he 
soon  starts  up  again,  screaming  with  a  fresh  attack  of  pain.  The  motions 
are  scanty  and  rare.  The  bowels  sometimes  remain  confined  for  twenty- 
foiu-  hours  or  longer,  and  when  they  are  at  last  relieved,  hard,  clay-col- 
o-ured  balls,  tinged  with  gTcen  mucus,  are  expelled  with  gTcat  effort  and 
straining.  These  balls  consist  of  hard  curd  and  farinaceous  matter.  A 
full  dose  of  castor-oil,  which  clears  ^way  the  curd,  allays  the  symptoms 
for  a  time  ;  but  usually,  if  the  same  diet  be  persisted  in  without  any 
change,  they  retui-n  in  a  day  or  two,  and  the  child  is  in  the  same  distress 
as  before. 

In  almost  all  cases  of  infantile  atrophy,  the  ordinary  uniform  course  of 
the  derangement  is  interrupted  by  intercurrent  attacks  of  vomiting  and 
diarrhoea.  These  a,ttacks  not  only  greatly  increase  the  rapidit}'  of  the 
wasting,  but,  if  of  great  severity,  may  bring  the  illness  abruptly  to  an  end. 

Troublesome  vomiting  in  a  young  baby,  the  consequence  of  gastric 
catarrh,  is  a  very  serious  ailment.  All  food  swallowed  is  instantly  re- 
turned, and  clear  fluid,  Hke  water,  or  bile-stained  mucus,  is  occasionally 
ejected.  The  vomited  matters,  and  even  the  breath  of  the  child,  have  an 
offensive,  sour  smell.  The  belly  is  swollen  and  often  seems  tender;  the 
hands  and  feet  are  very  difficult  to  keep  warm ;  the  eyes  grow  quickkv  hol- 
low; the  lids  close  imperfectly;  the  complexion  is  sallow  or  half  jaundiced, 
and  the  fontanelle  is  deeply  depressed.  At  first  the  tongue  is  thickly 
furred,  later  it  is  apt  to  have  a  red,  glazed  appearance.  The  child  is  very 
fretful.  He  soon  becomes  too  weak  to  cry  loudly,  but  whimpers  feebly  to 
himself  in  a  pitiful  way,  and  scarcely  seems  to  sleep  at  all.  If  no  diarrhoea 
comphcate  the  ailment,  the  bowels  are  confined,  and  the  patient  often 
seems  to  be  distui-bed  by  flatulence,  for  he  draws  up  his  legs  uneasily 


602  DISEASE  I^^   CniLDRE]S^. 

"with  a  troubled  grimace.  If  treatment  do  not  succeed  in  checking  the 
disorder,  the  vomiting  continues,  and  is  excited  by  the  least  movement. 
The  complexion  becomes  earthy,  the  hands  and  feet  gi'ow  purple,  and  the 
temperature  in  the  rectum  may  fall  as  low  as  96°  or  97°.  At  this  period, 
thrush  usually  ajjpears  in  the  mouth,  and  death  may  be  preceded  by 
symptoms  of  spurious  hydrocephalus. 

Steady,  persistent  vomiting  such  as  has  been  described,  is  less  common 
than  ai'e  shorter  attacks  of  sickness  accompanied  by  diarrhoea.  These  are 
apt  to  occiu'  in  children  at  an  early  period  of  the  atrophy,  and  must  be 
looked  upon  as  an  effori  of  natui'e  to  reheve  the  ahmentary  canal  of  its 
unwholesome  burden.  It  is  only  at  a  later  period  of  the  illness  that  they 
are  apt  to  become  obstinate,  and  when  thus  coniiiTQed,  the  ailment  is  very 
difficult  to  overcome.  A  chi'onic  diarrhoea,  such  as  is  elsewhere  described 
(see  page  633),  often  arises  in  the  coui'se  of  infantile  atrophy,  and,  if  not 
treated  judiciously,  determines  a  fatal  issue  to  the  illness.  In  most  cases, 
indeed,  death  is  the  consequence  of  a  persistent  looseness  of  the  bowels 
which  nothing  ■will  an'est.  But,  in  an  infant  reduced  to  a  weakly  state  by 
a  long  course  of  improper  food,  any  acute  ailment,  however  apparently 
tiiflirig  it  may  be,  will  often  prove  fatal.  A  new  symptom  occTiriing  at  a 
late  period  of  atrophy  is  therefore  to  be  regarded  with  very  serious  ap-  . 
prehension. 

Diagnosis. — A  state  of  extreme  emaciation  may  be  present  in  the  infant 
as  a  result  of  other  causes  than  injudicious  management  and  unwholesome 
feeding.  Infants,  the  subjects  of  inherited  syphilis,  are  often  excessively 
puny  and  feeble,  and  acute  tuberculosis  may  attack  a  child  of  a  few 
months  old  and  gravely  impair  the  nutrition  of  the  patient. 

In  the  first  case,  the  sjTnptoms  induced  by  the  s^^hihtic  poison  are 
sufficiently  distinct.  The  child  snuffles  and  cries  hoarsely.  His  skin  is  dry, 
wiinkled,  and  of  the  colour  of  old  parchment.  It  is  sprinkled  over  with 
the  characteristic  coppery  or  rust-coloui-ed  spots,  and  the  buttocks  and 
perinseum,  often,  also,  the  genitals  and  upper  parts  of  the  thighs,  are  the 
colour  of  the  lean  of  ham.  Mucous  tubercles  are  probably  to  be  discovered 
at  the  margin  of  the  anus  and  the  hps.  The  comers  of  the  mouth  are 
fissured,  and  the  nostiils  red-looking  and  excoriated.  The  bridge  of  the 
nose  is  flattened,  and  an  examination  of  the  belly  will  j)i'obably  detect 
enlargement  of  the  spleen.  None  of  these  sjTnptoms  are  to  be  found  in 
simple  infantile  atrophy.  The  eaiihy  tint  of  the  face  and  body  sometimes 
resulting  from  chronic  digestive  trouble  is  very  different  from  the  parch- 
ment-hke  hue  of  the  inherited  disease  ;  strophixLus,  arising  from  the  same 
cause,  can  hardly  be  mistaken  for  the  coppeiy  spots  of  sj-phihs  ;  and  hoai'se- 
ness,  snuffling,  and  the  other  sjnnptoms  which  have  been  enumerated,  are 
never  the  consequence  of  weakness  and  wasting,  however  profound. 

In  acute  tuberculosis,  the  temperatiu-e  is  elevated,  and  a  theimometer 
in  the  rectum  will  be  found  to  mark  100°  or  101°  in  the  evening.  In  in- 
fantile atrophy,  there  is  no  pyi*exia  ;  on  the  contrary,  the  bodily  heat  is 
usually  lower  than  in  health.  Moreover,  in  the  foiTaer  disease,  the  child 
coughs,  and  even  if  the  hmgs  are  not  the  seat  of  pneumonia,  a  chcking 
rhonchus  will  be  discovered  here  and  there  about  the  chest.  In  tuber- 
culosis, too,  a  slight  amount  of  oedema  of  the  legs  is  almost  invariably 
present  in  the  infant. 

Sj-philis  and  tuberculosis  having  been  excluded,  the  diagTiosis  is  easy. 
The  wasting  must  be  due  to  chronic  digestive  derangement,  or  to  unsuit- 
able food,  or  to  both  of  these  causes  combined.  In  the  case  of  either 
chronic  vomiting  or  chronic  diaiThcea,  the  chai'acteristic  s^Tajjtom  of  these 


INFANTILE   ATEOPHY — PROGNOSIS — TREATMENT.  603 

derangements  will  be  present.  Still,  in  many  eases  of  malnutrition,  where 
the  wasting-  is  extreme,  there  is  no  initabihty  of  stomach,  and  the  bowels 
are  habitually  confined.  In  these  cases  the  child  is  peevish  and  fretful. 
His  belly  is  distended,  and  his  skin  dry  and  dull-looking.  The  nasal  line 
encii'chng  the  corners  of  his  mouth  is  well-defined.  His  feet  are  often 
cold,  and  the  bodily  temperature  in  the  rectum  is  sub-normal  (97°-97.5''j. 
His  stools  consist  of  hard  light-coloured  balls,  or  of  unformed  putty-like 
matter.  The  child  is  subject  to  attacks  of  abdominal  pain,  and  is  very 
noisy  and  troublesome  at  night. 

Prognosis. — Unless  the  infant  be  reduced  to  a  state  of  extreme  weak- 
ness and  depression,  the  prognosis  is  not  unfavourable.  It  is  often  surpris- 
ing to  mark  the  immediate  improvement  which  takes  place  when  the  child 
is  put  to  the  breast,  or  is  supphed  with  a  food  he  is  capable  of  digesting. 
If  signs  of  spurious  hydrocephalus  have  been  noticed,  if  the  mouth  be  the 
seat  of  thrush,  or  if  a  chronic  diaiThoea  have  been  estabUshed,  the  progno- 
sis is  more  serious,  and,  indeed,  these  cases  often  end  unfavourably. 
Chronic  vomiting,  however,  can  usually  be  aiTested  by  judicious  treatment, 
if  the  infant  retain  sufficient  strength  to  respond  to  the  restorative  meas- 
ures adopted. 

Treatment. — In  endeavouring  to  improve  the  nutrition  of  a  child  who 
is  suffering  from  infantile  atrophy,  we  have  to  take  into  account  the  degree 
of  weakness  of  the  infant,  and  the  more  or  less  disordered  state  of  his  diges- 
tive organs.  If  a  wet  nurse  can  be  procured,  a  return  to  the  breast,  if  the 
child  can  be  persuaded  to  take  it,  usually  arrests  at  once  all  unfavourable 
symptoms  ;  especially,  if  the  alteration  in  the  mode  of  feeding  be  aided  by 
an  aperient  dose  of  castor-oil,  followed  by  an  antacid  and  stomachic  mix- 
ture. In  many  cases,  however,  this  method  of  treatment  is  not  within  our 
reach,  and  we  have  to  trust  to  a  judicious  revision  of  the  child's  dietary 
and  general  management. 

The  successful  rearing  of  an  infant  by  artificial  means  is  not  a  difficult 
matter.  It  requires  intelligence  and  tact ;  but,  above  all,  it  reqmres  watch- 
fulness. If  we  are  vigilant  to  detect  the  first  signs  of  discomfort  and  acid- 
ity, and  at  once  modify  the  diet  accordingly,  we  may  be  sure  of  preserv- 
ing a  healthy  tone  in  the  stomach,  and  warding  off  all  the  accidents  to 
which  a  child  less  carefully  nui'tured  might  possibly  succumb. 

During  the  first  month  after  birth,  the  infant  usuaUy  is  able  to  obtain 
some  milk  from  its  mother's  breast.  This,  however,  may  have  to  be  sup- 
plemented by  other  food,  and  sometimes  the  babe  is  forced  to  depend 
entirely  upon  artificial  feeding  fi'om  the  beginning.  For  the  first  six 
weeks  he  may. be  fed  with  condensed  milk  diluted  with  water,  or  thin  bar- 
ley-water, in  the  proportion  of  one  teaspoonful  of  the  milk  to  the  half  bot- 
tle. Preserved  milk  at  this  time  almost  invariably  agrees  well.  Care  must, 
however,  be  taken  to  use  only  milk  from  a  tin  which  has  been  newly- 
opened  ;  for  when  exposed  to  the  air,  the  milk,  although  still  apparently 
fresh,  rapidly  breeds  bacteria,  and  becomes  unfit  for  the  child's  consump- 
tion. In  hot  weather,  too,  the  barley-water  should  be  freshly  made  twice 
in  the  day.  Like  the  condensed  milk,  it  must  be  kept  in  a  refrigerator  or 
other  cool  j)lace,  and  should  never  be  heated  to  the  boiling  point  after  it 
has  once  been  made,  as  to  do  so  excites  rapid  fermentation. 

After  six  weeks,  or,  at  the  most,  two  mouths,  have  elapsed  from  birth,  the 
child  should  be  put  upon  cow's  milk.  It  is  important,  especially  in  warm 
weather,  that  this  should  be  perfectly  fresh.  If  slightly  acid  from  keep- 
ing, as  it  often  is  when  delivered  at  the  bouse,  the  acidity  shoiild  be  neutral- 
ised by  the  addition  of  a  httle  carbonate  of  soda. 


604  DISEASE  IJST   CHILDEEN. 

To  make  this  milk  an  efficient  substitute  for  human  breast-milk,  it  will 
not  be  sufficient  to  sweeten  it  with  sugar  and  dilute  it  with  water.  It  is 
necessary,  in  addition,  to  prevent  the  fii-m  clotting  of  its  curd  under  the 
action  of  the  gastric  juice.  This  may  be  done  by  using  hme-water  to  di- 
lute the  milk,  adding  it  in  sufficient  quantity  to  partially  neutrahse  the 
gastric  secretion,  and  thus  in  a  great  measure  prevent  coagulation  in  the 
stomach.  To  do  this  effectually,  at  least  a  third-part  of  the  mixture  should 
consist  of  lime-water.  To  two  tablespoonfuls  of  fresh  milk,  add  an  equal 
quantity  of  hot  filtered  water,  and  alkalinise  by  two  tablespoonfuls  of  lime- 
water.  The  infant  should  suck  this  food  from  a  feeding-bottle.  Its  tem- 
perature when  taken  should  be  95°.  If  too  cool  after  being  prepared,  the 
feeding-bottle  should  be  allowed  to  stand  for  a  few  minutes  in  a  little 
basinful  of  hot  water. 

Another  plan  by  which  the  casein  of  cow's  milk  may  be  made  digest- 
ible, consists  in  mechanically  separating  the  particles  of  curd  by  the  addi- 
tion of  some  thickening  substance,  such  as  gelatine  or  barley-water.  This 
method  of  preiDaring  the  milk  is  to  be  preferred  to  the  previous  one,  as  it 
leaves  the  gastric  juice  unaltered,  and  does  nothing  to  impair  the  child's 
digestive  power.  It  merely  forces  the  curd  to  form  a  multitude  of  small 
clots,  instead  of  running  together  into  one  large,  dense  lump.  For  a  child 
of  two  months  of  age,  the  milk  should  be  diluted  with  an  equal  quantity 
of  barley-water,  and  be  sweetened  with  a  small  teaspoonful  of  sugar  of 
milk. 

The  proportion  of  milk  taken  by  the  infant  for  each  meal  should  be 
gradually  increased  as  he  grows  older.  From  a  half,  the  quantity  may  rise 
by  degTees  to  two-thiixls,  and  then  to  three-fourths,  and  a  larger  quantity 
of  milk-sugar  may  also  be  added. 

Barley-water  rarely  disagrees  even  with  the  youngest  infants,  although 
in  them,  the  capacity  for  digesting  starch  is  very  feeble,  as  has  been  already 
explained.  If  preferred,  however,  instead  of  barley-water,  the  milk  may 
be  diluted  with  plain  water,  and  the  thickening  material  be  supplied  by  a 
teaspoonful  of  isinglass  or  gelatine.  MeUin's  food,  too,  may  be  used  from 
the  first,  and  is  almost  always  well  digested. 

Farinaceous  matters,  unless  guarded  by  malt,  as  in  MeUin's  food,  should 
not  be  given  to  a  child  younger  than  six  months. 

The  milk  prejDared  in  one  of  the  ways  described  must  be  given  in  suit- 
able quantities  and  at  regular  intervals.  Six  or  eight  tablespoonfuls  will 
be  enough  to  make  a  meal  for  an  infant  of  fovir  or  five  weeks  old.  The 
child  should  take  his  food  half  recUning,  as  when  in  his  mother's  arms, 
and  the  bottle  must  be  removed  directly  its  contents  are  exliausted.  After 
taking  his  food,  the  child  should  sleej)  for  two  hours.  Any  sign  of  fretful- 
ness  or  discomfort  at  this  age  must  be  taken  to  imply  indigestion  and 
flatulence.  If  this  be  the  case,  a  teaspoonful  of  some  aromatic  water,  such 
as  cinnamon  or  dill,  may  be  added  to  the  next  bottle  of  food.  The  feeding 
apparatus  must  be  kept  perfectly  clean.  It  is  well  to  wash  out  the  bottle 
directly  after  it  has  been  used,  with  soda  and  water,  and  then  to  let  it  stand 
in  cold  water  imtil  again  required.  It  is  desk-able  to  have  two  bottles  and 
to  use  them  alternately. 

When  the  child  is  six  months  of  age  he  may  begin  to  take  farinaceous 
food.  A  teaspoonful  of  Chapman's  entire  wheaten  flom-,  baked  in  an  oven, 
can.be  given  once  or  twice  a  day,  rubbed  up,  not  boiled,  with  milk.  Tl 
there  is  constipation,  a  similar  quantity  of  fine  oatmeal  may  be  used  in- 
stead, of  the  flour.  AVhen  the  farinaceous  food  is  first  begun,  a  teaspoonful 
of  the  flour  rubbed  up  with  milk  can  be  added  to  the  meal  of  milk  thick- 


ITSTFAISTTILE   ATEOPHY — TEEATMENT.  605 

ened  with  Mellin's  food.  Later,  the  flour  can  be  given  with  milk  as  a  sep- 
arate meal. 

No  beef-tea  or  broth  should  be  allowed  until  the  baby  is  at  least  ten 
months  of  age.  At  that  time  he  may  begin  to  take  weak  beef,  veal,  or 
mutton  broth,  and  may  also  have  the  yolk  of  an  egg  Hghtly  boiled,  or 
beaten  up  with  milk  in  the  bottle.  The  child  may  take  light  pudding  at 
the  age  of  twelve  months,  but  no  meat  for  several  months  longer. 

AH  changes  made  in  the  diet  from  the  earhest  period  to  the  latest 
should  be  made  cautiously,  and  their  effect  carefuUy  observed.  If  the 
meal  appear  to  excite  i»digestion  and  flatulence,  the  new  food  must  be 
given  on  the  next  occasion  in  smaller  quantity,  or  we  may  wait  for  a  week 
before  giving  it  a  second  time. 

Scrupulous  cleanhness,  and  the  purest  air  attainable,  are  of  great  im- 
portance. The  child  should  be  washed  over  the  whole  body  twice  a  day — 
once  with  soap.  He  should  wear  a  flannel  binder  round  the  belly.  No 
slops  or  soiled  linen  should  be  allowed  to  remain  in  the  nursery,  and  the 
window  of  the  room  should  be  kept  open  as  much  as  is  practicable.  The 
infant  should  be  taken  out  of  doors  for  several  hom-s  in  the  day  ;  and  while 
every  care  is  taken  to  guard  his  sensitive  body  against  sudden  changes  of 
temperature,  he  must  not  be  covered  up  by  too-heavy  clothes,  and  shut  off 
from  every  breath  of  air  for  fear  of  his  catching  cold.  A  child  ought  to  lie 
cool  at  night,  and  the  furniture  of  his  cot,  although  sufficiently  thick  to 
insure  necessary  warmth,  should  not  be  cumbersome  so  as  to  be  a  burden. 

The  above  directions,  strictly  carried  out,  will  be  found  to  succeed  in 
most  cases  where  the  child's  digestive  organs  have  not  been  irritated  and 
weakened  by  unsuitable  meals.  Often,  however,  the  infant  only  comes  un- 
der observation  after  attempts — more  or  less  injudicious— have  been  made 
to  rear  him,  and  advice  is  sought  because  the  measures  adopted  have  been 
found  to  be  unsuccessful.  Exceptional  cases  are  also  sometimes  met  with, 
where  the  infant  from  the  first  is  unable  to  digest  cow's  milk.  However 
carefully  the  food  may  be  prepared,  each  meal  either  excites  vomiting,  or 
produces  great  acidity  and  flatulence,  and  the  general  nutrition  of  the  child 
becomes  gTadually  impaired. 

In  every  case  of  milk  indigestion,  we  should  inquire  carefully  as  to  the 
time  of  feeding,  the  quantity  supphed  at  each  meal,  and  the  attention  be- 
stowed upon  cleanliness  in  the  feeding  apparatus. 

The  inability  to  digest  cow's  milk  may  be  a  natural  peculiarity  of  the 
infant,  or  a  merely  temporary  incapacity  arising  from  a  disordered  state  of 
the  digestive  organs.  In  the  first  case,  if  a  wet-nurse  cannot  be  procured, 
or  is  objected  to,  we  may  give  the  milk  of  the  goat  or  ass.  Either  of  these 
is  usually  weU  digested  by  children  who  find  cow's  milk  too  heavy.  The 
addition  of  a  third  or  fourth  part  of  barley-water  still  further  increases  the 
digestibihty  of  the  meal,  and  Mellin's  food  may  be  dissolved  in  the  mixture 
with  advantage.  Both  these  milks  should  be  boiled  before  being  used. 
Ass's  milk  sometimes  has  laxative  properties  which  boiling  will  remove. 
By  the  same  means  the  strong  flavour  of  goat's  milk  may  be  diminished, 
although  this  is  often  not  objected  to  by  the  infant.  An  aromatic,  such  as 
a  couple  of  teaspoonfuls  of  cinnamon  water,  added  to  the  milk,  seems  often 
to  supply  a  stimulus  to  digestion  ;  and  I  have  known  infants  who  were 
invariably  troubled  with  flatulence  and  discomfort  after  a  meal  of  plain 
cow's  milk  and  barley-water,  digest  perfectly  the  same  mixture  when  thus 
aromatised.  If  test  paper  show  slight  acidity  of  the  milk,  a  pinch  of  bi- 
carbonate of  soda  should  be  always  added  to  the  bottle. 

Condensed  milk  is  often  recommended  in  these  cases,  and  is  usually 


C06  DISEASE   IIS^   CHILDEEN. 

well  digested,  but  the  nourisliment  it  supplies  is  very  insufficient  for  a 
growing  babj'.  The  child  may  get  fat,  but  is  usually  lethargic  and  dull. 
Although  big,  he  is  not  strong ;  and  unless  the  milk  be  largely  supplemented 
by  Mellin's  food,  the  infant  will  probably  drift  into  rickets  before  he  is 
seven  or  eight  months  old.  The  same  maybe  said  of  the  other  foods  con- 
taining jDreserved  milk,  as  Nestle's  and  OettU's  Swiss  milk  food.  They 
are  often  more  easily  digested  than  undiluted  cow's  milk,  but  after  the 
first  few  months  should  not  be  relied  upon  to  sujDply  the  whole  nourish- 
ment of  the  baby.  In  all  cases  it  is  advisable  to  revert  to  fresh  cow's  milk 
as  soon  as  this  can  be  done  with  safety.  There  *ls  another  reason  why  an 
infant  should  not  be  allowed  to  derive  his  whole  nourishment  from  tinned 
and  preserved  foods.  It  is  now  a  recognised  fact  that  hand-fed  babies 
are  liable  to  a  form  of  scurvy ;  and  if  the  child  be  entirely  deprived  of 
fresh  milk  and  other  anti-scorbutic  foods,  this  consequence  of  injudicious 
feeding  is  very  likely  to  be  brought  about  (see  page  253). 

It  is  in  cases  where  ordinary  cow's  milk  is  digested  with  difficulty  that 
Dr.  Robert's  plan  of  pancreatising  the  milk  is  so  valuable.  Pancreatised 
milk  is  prepared  in  the  following  way  : — To  a  pint  of  new  cow's  milk  is 
added  half  a  pint  of  boihng  water,  two  teaspoonfiils  of  Benger's  pancreatic 
solution,  and  twenty  grains  of  bicarbonate  of  soda  dissolved  in  a  little 
water.  The  whole  is  stirred  up  in  a  jug,  which  is  afterwards  covered,  and 
then  j)laced  in  a  warm  situation  under  a  "  cosey."  At  the  end  of  an  hour, 
the  contents  of  the  jug  are  emptied  into  a  sauce-pan,  and  the  mixture  is 
boiled  for  two  minutes  to  stop  fui'ther  action  of  the  pancreatine  upon  the 
milk.  The  food  is  then  ready  for  use.  It  may  be  sweetened  to  the  child's 
taste  with  sugar  of  milk.  In  milk  so  prepared,  the  casein  is  peptonised  by 
the  action  of  the  pancreatine,  and  the  main  difficulty  in  the  digestion  of 
the  milk  is  removed.  This  method  is,  in  my  opinion,  far  preferable  to  that 
suggested  by  Prof.  Frankland.  In  the  latter  method  {artificial  human  milk), 
the  cow's  milk  is  diluted  with  a  third  part  of  whey,  and  no  doubt  by  this 
means  the  normal  proportion  of  casein  in  woman's  milk  may  be  exactly 
imitated  ;  but  the  process  does  nothing  to  render  the  stiff  curd  more  di- 
gestible, and  the  firm  clotting  of  the  casein  is  just  the  difficulty  which  it  is 
so  essential  to  overcome. 

A  temporary  incapacity  for  digestmg  milk  on  account  of  gastric  de- 
rangement, is  a  common  phenomenon  in  the  young  child,  and,  indeed,  is 
the  most  frequent  cause  of  failure  in  hand-feeding.  If  a  change  be  not 
made  in  a  diet  which  evidently  disagxees,  it  is  not  long  before  a  catarrh 
of  the  gastric  mucous  membrane  becomes  estabhshed.  This  derange- 
ment, when  once  confirmed,  is  not  always  easy  to  control,  and,  if  very 
stringent  measures  are  not  promptly  taken,  may  lead  to  the  death  of  the 
child.  A  mild  form  of  gastric  disturbance  sufficient  to  prevent  the  diges- 
tion of  milk,  is  not  unfi'equently  met  with,  even  in  children  at  the  breast. 
It  is  indicated  by  a  sour  smeU  from  the  mouth,  a  sUght  saUow  tinge  of  the 
skin,  and  by  the  vomiting  of  each  meal  directly  after  it  has  been  swallowed. 
Sometimes  the  bowels  are  relaxed,  from  participation  of  the  intestinal 
mucous  membrane  in  the  derangement.  A  condition  such  as  this  may 
exist  almost  from  bu'th.  It  is  a  common  accident  in  hand-fed  babies,  and 
if  neglected,  leads,  as  has  been  said,  to  serious  and  perhaps  fatal  conse- 
quences. 

In  children  at  the  breast,  the  derangement  is  usually  quickly  remedied 
by  the  administration  two  or  thi'ee  times  a  day  of  a  few  grains  of  bicarbon- 
ate of  soda,  and  half  a  ch-op  of  the  tincture  of  nux  vomica,  in  a  teaspoonfiil 
of  some  aromatic  water.     In  infants  artificially  fed,  the  disorder  is  not  so 


INFANTILE   ATROPHY — TEEATMENT.  607 

easily  cured,  and  a  complete  change  in  the  diet  will  be  required.  The 
pancreatised  milk  is  very  useful  in  these  cases,  and  in  conjunction  with  the 
alkaline  mixture  just  referred  to,  will  often  quickly  restore  the  digestive 
organs  to  a  healthy  condition.  If  this  do  not  succeed,  it  will  be  necessary 
to  stop  all  milk-foed  for  a  day  or  two.  The  youngest  infants  bear  a  tem- 
porary deprivation  of  milk  exceedingly  well ;  and  when,  as  in  the  derange- 
ment spoken  of,  the  symptoms  are  the  direct  consequence  of  fermentation 
and  acidity,  a  withdrawal  of  the  fermentable  material  is  followed  by  im- 
mediate and  striking  improvement.  Even  in  the  most  obstinate  and  pro- 
tracted cases  of  gastric  derangement  in  young  babies,  the  withholding  of 
milk-food,  combined  with  proper  measures  to  support  the  strength  and 
maintain  the  heat  of  the  body,  will  be  generally  successful  in  restoring  the 
infant  to  health.  The  same  treatment  is  of  equal  service  in  cases  of  severe 
acute  gastric  catarrh  in  hand-fed  babies. 

Some  time  ago  I  was  asked  to  see  an  infant  two  months  old,  whom  I 
found  suffering  from  acute  gastric  catarrh,  and  in  a  state  of  great  exhaustion. 
She  had  been  brought  up  by  hand,  and  was  being  fed  upon  milk  and  bar- 
ley-water in  equal  proportions.  This  she  vomited  as  soon  as  it  had  been 
GwaUowed,  bringing  it  up  curdled  and  intensely  acid.  There  was  a  sour 
smeU  from  the  breath,  and  although  the  disease  had  only  lasted  a  few 
days,  the  eyes  were  hoUow,  the  face  looked  pinched,  the  fontanelle  was 
deeply  depressed,  and  she  lay  motionless  on  the  nurse's  lap  with  her  eyes 
half  closed.  Her  hands  and  feet  were  cold  to  the  touch  and  looked  purple. 
For  a  day  or  two  her  bowels  had  been  much  relaxed.  She  was  taking  small 
doses  of  lead  and  opium  to  check  the  diarrhoea,  but  each  dose  was  returned 
almost  immediately'.  The  child  was  ordered  to  be  kept  warm  and  perfectly 
quiet.  A  week  mustard  poultice  was  applied  for  an  hour  to  the  epigastrium. 
The  mUk  was  stopped,  and  the  child  was  fed  with  weak  veal  broth  and  thin 
barley-water  mixed  together  in  equal  proportions,  and  given  cold  at  inter- 
vals with  a  teaspoon.  A  few  drops  of  brandy  were  also  given  occasionally, 
as  seemed  desirable.  As  a  result  of  this  treatment,  the  vomiting  stopped 
at  once,  and  the  child  when  seen  three  days  afterwards  was  found  to  be 
greatly  improved.  The  breath  had  lost  its  sour  smell,  the  face  was  no 
longer  pinched,  the  eyes  were  not  hollow,  the  fontanelle  was  not  depressed, 
and  when  asleep  the  child  closed  her  eyelids.  The  motions  were  still 
rather  watery,  although  the  number  was  natural.  The  medicine  and  diet 
were  continued  for  a  few  days  longer,  and  the  child  was  soon  well. 

The  most  important  part  of  the  treatment  in  this  case  was  the  substitu- 
tion of  veal  broth  for  milk.  Directly  the  supply  of  fermentable  matter  was 
stopped,  fermentation  ceased,  acid  was  no  longer  formed,  and  the  digestive 
organs  returned  to  a  healthy  condition.  Here  the  derangement  was  acute. 
In  the  following  case  the  complaint  was  chronic,  the  inability  to  digest 
cow's  milk  having  extended  over  a  lengthened  period. 

A  little  gui,  ten  months  of  age,  very  thin  and  weakly-looking,  had  been 
weaned  at  the  age  of  eight  months.  Since  that  time  she  had  been  unable 
to  digest  milk,  vomiting  it  at  once  whenever  it  was  given  to  her.  For 
nearly  two  months,  therefore,  she  had  been  fed  on  two  dessert-spoonfuls 
of  farinaceous  food  made  with  water  into  a  thick  cream,  and  given  every 
two  hours  with  a  spoon.  She  refused  to  take  it  from  a  bottle.  Twice  a 
day  the  food  was  made  with  beef-tea  instead  of  with  water.  After  a  meal 
the  child  often  vomited,  but  when  this  happened  she  was  immediately  fed 
again.  The  result  of  such  a  diet  was  to  be  expected.  The  child,  although 
ten  months  old,  could  not  sit  up.  She  was  becoming  rapidly  thinner.  She 
slept  very  little,  crying  and  whining  the  greater  part  of  the  night.     She  was 


608  DISEASE   IN   CHILDRElSr. 

said  to  show  no  signs  of  abdominal  pain,  but  tbe  bowels  acted  three  times 
a  day,  and  the  motions  were  relaxed  and  horribly  offensive.  The  feet  were 
almost  always  cold. 

Such  a  case,  which  is  far  from  being  an  uncommon  one,  is  readily  treated, 
however  severe  may  be  the  vomiting,  by  restricting  the  diet  to  equal  parts 
of  weak  veal  broth  and  thin  barley-water,  given  cold  in  small  quantities  at 
a  time  ;  by  warmth  to  the  belly  and  extremities  ;  by  perfect  quiet,  and  by 
suitable  remedies.  The  best  sedative  is  liq.  arsenicalis — half  a  drop  for 
the  dose — given  with  a  few  grains  of  bicarbonate  of  soda  in  some  aromatic 
water.  It  may  be  sweetened  with  spirits  of  chloroform.  After  a  few  days 
of  such  treatment,  the  power  of  digesting  milk  usually  returns.  But  at 
first  it  should  be  given  sparingly,  either  pancreatised,  or  freely  diluted  with 
barley-water,  and  only  once  or  twice  in  the  day.  If  the  inability  to  digest 
milk  continue,  the  case  must  be  treated  as  described  under  the  head  of 
Chronic  Diarrhoea  (see  page  640). 

It  may  be  necessary  to  begin  the  treatment  by  a  dose  of  castor-oil,  or 
rhubarb  and  soda,  to  clear  away  undigested  food  from  the  bowels.  If  the 
child  is  very  weak,  white  wine  whey  '  is  very  useful.  This  may  be  sucked 
from  a  feeding-bottle,  or  given  with  a  syringe-feeder,  and  the  infant,  if 
feeble,  may  take  it  in  large  quantities.  Alternate  meals  of  this  whey,  and 
of  weak  veal  broth  diluted  with  an  equal  proportion  of  thin  barley-water, 
forms  a  very  suitable  diet  for  such  cases.  MeUin's  food,  dissolved  in  thin 
barley-water,  or  plain  whey  and  barley-water,  is  also  very  useful ;  and  a 
dessert-spoonful  of  fresh  cream,  shaken  up  with  a  teacupful  of  plain  or 
white  wine  whey,  is  a  very  valuable  resource  in  obstinate  cases. 

For  the  treatment  of  constipation,  colic,  looseness  of  the  bowels,  thrush, 
and  the  other  accidents  attendant  upon  improper  feeding  and  general  mis- 
management, the  reader  is  referred  to  the  chapters  treating  of  these  special 
subjects.  In  conclusion,  it  may  again  be  remarked  that  success  in  the  arti- 
ficial feeding  of  infants  depends,  in  the  first  place,  upon  the  selection  of  a 
suitable  diet ;  and  in  the  second,  upon  extreme  watchfulness  to  detect  the 
earhest  signs  of  indigestion  and  acidity,  and  to  make  the  necessary  changes 
in  the  food  which  have  been  indicated  above.  Action  must  be  prompt,  for 
delay  is  often  fatal.  A  food  must  be  changed  directly  it  ceases  to  agree, 
and  any  symptom  of  indigestion  mvist  be  met  at  once  with  a  suitable 
remedy.  A  derangement  which  in  the  beginning  might  have  been  arrested 
without  difficulty  soon  assumes  serious  proportions,  and  if  allowed  to  con- 
tinue, will  quickly  bring  a  weakly  infant  to  the  grave. 

'  To  make  white  wine  whey : — Put  a  breakfastcupful  of  new  milk  in  a  saucepan  on 
the  fire.  When  it  comes  to  the  boil,  add  a  wineglassful  of  sound  sherry.  Then  boil 
again  for  one  minute  and  strain  ofE  the  curd.     Sweeten  with  white  sugar. 


CHAPTER  II. 

GASTRIC  CATAREH. 

Catareh  of  the  stomach  in  early  life  is  a  derangement  of  common  occur- 
rence. It  is  met  with  in  two  forms — a  febrile  and  a  non-febrile  variety. 
A  first  attack  renders  the  gastric  mucous  membrane  more  susceptible 
than  before,  and  predisposes  to  a  second  :  on  this  account,  the  disorder  is 
frequently  found  to  recur  repeatedly  in  the  same  subject,  and  serious  in- 
terference with  the  child's  nutrition  may  be  the  consequence.  Catarrh  of 
the  stomach,  unaccompanied  by  fevex',  is  perhaps  the  commonest  derange- 
ment to  which  children  are  exposed.  It  is  a  perpetual  danger  to  hand-fed 
babies,  and  forms,  indeed,  the  chief  obstacle  to  the  successful  rearing  of 
infants.  The  disorder  as  met  with  in  early  infancy  has  been  already  de- 
scribed (see  Infantile  Atrophy).  The  present  chapter  treats  only  of  catarrh 
as  it  affects  older  children,  after  the  period  of  infancy  has  passed  by. 

Causation. — In  childhood,  the  mucous  membrane  is  especially  liable  to 
be  affected  by  chills,  but  the  "cold"  does  not  always  show  itself  in  the 
form  of  sore-throat  or  cough.  A  gastric  or  intestinal  disorder  is  a  famil- 
iar consequence  of  exposure  to  changes  of  temperature,  and  to  this  cause 
most  cases  of  the  derangement  can  be  attributed.  A  child  who  has  suf- 
fered from  many  such  attacks,  often  acquires  an  exti'aordinary  susceptibility 
to  alternations  of  temperature,  and  the  most  trifling  chill  will  be  sufficient 
to  induce  a  return  of  his  complaint.  In  such  children,  the  mere  going  out 
with  cold  feet  into  raw,  damp  air,  is  a  common  cause  of  a  fresh  attack.  In- 
sufficient clothing  is  sometimes  the  sole  catise  of  the  derangement.  Chil- 
dren whose  parents  have  a  foolish  objection  to  flannel,  often  suffer  greatly 
from  continued  catai'rhs.  I  have  known  cases  where  complete  loss  of  ap- 
petite and  persistent  wasting  resulted  from  this  deficiency,  and  ceased  at 
once  when  proper  measures  were  taken  to  protect  the  child's  body  from 
the  cold. 

Certain  constitutional  states  predispose  the  child  to  be  readily  affected 
by  chiUs.  In  rickets,  a  susceptibility  to  catarrh  is  a  marked  feature  of  the 
disease.  Pulmonary  and  gastric  catarrhs  are  of  constant  occun-ence  in  such 
subjects,  and  if  the  disease  be  present  in  a  severe  form,  may  lead  to  a  rap- 
idly fatal  issue.  Scrofulous  children,  again,  are  very  prone  to  suffer  from 
catarrhal  disorders,  and  gastric  derangement  in  them  is  very  common  from 
this  cause.  There  is  one  peculiarity  of  gastric  catarrh,  as  it  occurs  in  scrof- 
ulous subjects,  which  is  of  importance.  It  is  that  the  complaint  is  almost 
invariably  accompanied  with  fever.  In  such  children,  the  recurring  attacks 
of  pyrexia,  lasting  from  a  few  days  to  a  week,  which  are  often  complained 
of,  are  cases  of  the  febrile  variety  of  acute  gastric  catarrh. 

During  the  second  dentition,  the  trifling  febrile  distm-bance  which  is. 
excited  by  the  passage  of  the  tooth  through  the  gum,  may  render  the  child 
very  susceptible  to  chiUs,  and  attacks  of  gastric  catarrh  at  this  time  are 
very  common. 
39 


610  DISEASE   IE"   CHILDliEN. 

Besides  exposure  to  cold,  irritation  of  the  mucous  membrane  by  un- 
suitable food  may  be  a  soiu'ce  of  catarrh.  In  infants,  as  has  been  already 
described,  this  is  the  cause  to  which  the  derangement  can  be  most  com- 
monly attributed.  In  older  children,  also,  gastric  catarrh  may  be  pro- 
duced by  similar  means,  and  may  be  set  up  by  excess  of  rich  sauces,  fruit, 
or  sweets.  As  in  the  case  of  a  chill,  the  susceptibility  to  suffer  from  these 
causes  may  be  increased  by  temporary  or  constitutional  states.  During  the 
evolution  of  a  tooth,  food  Which  would  be  readily  digested  at  another  time, 
is  often  found  to  disagree. 

Morbid  Anatomy. — A  mucous  membrane,  the  seat  of  catarrh,  is  injected 
in  spots,  and  a  layer  of  tough  mucus  covers  its  surface.  In  the  stomach  the 
mucous  surface  is  often  found  softened  ;  but  this  condition,  which,  under 
the  name  of  gelatinous  softening,  or  gastro-malacia,  was  at  one  time  re- 
garded as  a  pathological  feature  of  great  importance,  and  the  cause  of  the 
symptoms  which  had  been  observed  dru-ing  Hfe,  is  now  admitted  to  be  a 
mere  post-mortem  change  which  has  no  practical  significance.  The  gastric 
membrane  is  thickened,  and  exhibits  joatches  of  redness.  The  stomach 
often  contains  much  mucus,  and  not  unfrequently  fermenting  food. 

Symijtoms. — Attacks  of  gastric  catarrh  may  or  may  not  be  accompanied 
by  elevation  of  temperature.  The  severe  acute  attack,  with  high  fever,  is 
the  less  common,  and  is  limited,  or  nearly  so,  to  the  subjects  of  struma. 
The  subacute,  non-febrile  gastric  derangement  is  much  more  often  met 
with.  It  is  milder  in  character  and  more  quickly  subsides  :  indeed,  from 
the  slightness  of  the  symptoms  by  which  it  is  accompanied,  the  attack  may 
pass  almost  unnoticed,  or  be  spoken  of  as  "liver"  or  "biliousness." 

In  the  acute  febrile  form,  the  child  feels  chiUy,  or  even  shivers,  and  then 
becomes  very  feverish,  the  temperature  rising,  perhaps,  in  the  evening  of 
the  first  day  or  two,  to  104°.  The  j)atient  complains  of  no  pain,  but  is 
languid  and  irritable.  He  has  a  sallow  complexion,  and  looks  dark  under 
the  eyes,  but  his, general  expression  is  placid,  and  unless  the  child  is  tired 
by  exercise,  there  is  none  of  the  pinched,  haggard  asjDect  which  is  so  com- 
mon in  cases  of  really  serious  illness.  The  appetite  is  lost,  and  there  is 
some  thirst.  The  tongue  is  usually  furred  on  the  dorsum,  but  may  be 
clean  and  red  at  the  tip  and  edges.  Vomiting  is  not  common,  but  may 
occur,  although  it  is  rarely  distressing.  If  the  catarrh  affect  the  intestinal 
mucous  membrane  as  well  as  that  of  the  stomach,  there  is  some  diarrhoea  ; 
otherwise  the  bowels  are  confined.  Purging,  if  present,  may  be  accom- 
panied by  some  pain  in  the  belly,  but  this,  as  a  rule  is  insignificant.  At 
night  the  child  is  often  restless,  and  is  disturbed  by  dreams  from  which  he 
may  wake  in  great  terror.  During  the  day,  if  the  catarrh  is  severe,  he  is 
generally  drowsy,  and  sits  or  lies  about  without  wishing  to  join  in  the 
sports  of  his  companions.  While  the  attack  lasts,  nutrition  is  in  abeyance, 
and  the  flesh  and  strength  manifestly  suffer.  After  a  week  or  ten  days, 
the  pyrexia,  which  had  been  gradually  subsiding,  disappears  ;  the  appe- 
tite and  spirits  return,  and  the  j^atient  is  convalescent. 

Often  the  gastric  catarrh  is  accompanied  by  symj)toms  pointing  to  a 
similar  condition  of  other  tracts  of  mucous  membrane.  The  child  may  suf- 
fer slightly  from  catarrh  of  the  nose  ;  the  throat  may  be  a  little  sore  ;  the 
eyes  may  be  weak  and  distressed  by  a  strong  light,  or  there  may  be  slight 
cough.  Even  if  the  fever  is  high,  delirium  is  not  common,  but  there  is  oc- 
casionally some  frontal  headache.  If  the  catarrh  pass  along  the  duodenum 
to  the  common  bile  duct,  a  mild  jaundice  is  noticed. 

In  many  cases,  an  attack  such  as  the  above  passes  off,  and  the  child  does 
not  suffer  again  from  a  similar  illness.     Often,  however,  the  catarrh,  instead 


GASTRIC    CATARRH — SYMPTOMS.  611 

of  occurring  in  one  solitary  instance,  returns  repeatedly  at  short  intervals. 
Cases  of  recurring  gastric  catarrh  of  greater  or  less  severity  are  far  from 
uncommon  ;  and  these  attacks,  if  the  intervals  between  them  are  short,  may 
exercise  a  very  injurious  influence  upon  the  health  and  general  development 
of  the  patient.  Children,  the  subjects  of  such  catarrhs,  become  pale  and 
thin,  for  their  nutrition  is  being  constantly  interrupted.  By  its  influence 
upon  appetite  and  digestion,  the  catarrh  checks  for  a  time  the  introduction 
of  nourishment  into  the  system,  and  nutrition  is  hardly  restored  on  the 
cessation  of  the  attack  when  a  return  of  the  derangement  suspends  it  again 
as  before.  In  this  way  the  child  may  become  an  almost  constant  sufferer 
from  disordered  stomach,  and  his  continued  ill  health  and  persistent  wast- 
ing excite  the  gravest  apprehensions  amongst  his  relatives.  Such  cases 
are  often  supposed  to  be  cases  of  consumption  ;  and,  indeed,  if  there  be  any 
inherited  chest  weakpess,  long-continued  interference  with  nutrition,  such 
as  is  produced  by  a  frequent  recurrence  of  these  attacks,  may  go  far  to  en- 
courage the  tendency  to  phthisis. 

In  the  non-febrile  variety,  the  symptoms  are  much  less  striking,  for,  py- 
rexia being  absent,  the  spirits  are  less  depressed  and  the  patient  utters  no 
complaint.  Most  children  suffer  at  times  from  what  is  called  "  biliousness," 
For  tAvo  or  three  days  together  they  lose  their  appetite,  mope  and  lie  about, 
have  a  duU,  pasty  or  sallow  complexion,  and  look  dark  under  the  eyes.  At 
night  they  sleep  badly,  and  they  are  restless  and  irritable  in  the  day.  These 
symptoms  are  produced  by  a  temporary  catarrh  of  the  stomach  which  in- 
terferes for  the  time  with  the  digestion  of  food,  but  passing  off,  leaves  no 
ill  consequences  behind.  When,  however,  the  attacks  are  frequent,  diges- 
tion is  weak,  even  in  the  intervals  of  comparative  health,  and  nutrition  be- 
comes seriously  impaired.  Such  children  complain  often  of  flatulent  pains 
in.  the  sides,  and  may  be  subject  to  attacks  of  syncope  from  pressure  up- 
wards of  the  distended  stomach  against  the  heart.  Their  bowels  are  usually 
costive.  The  appetite  varies  greatly.  Sometimes  it  is  excessively  keen  ; 
at  others  it  is  poor  and  capricious.  In  nasinj  cases,  indeed,  the  child  seems 
to  have  no  appetite  at  all,  and  the  greatest  difficulty  is  experienced  in  mak- 
ing him  swallow  his  food. 

These  symptoms  may  be  greatly  aggravated  by  an  unsuitable  dietary. 
If  a  child  who  suffers  from  the  condition  described  be  supplied  with  an  ex- 
cess of  fermentable  food,  such  as  potatoes,  puddings,  jams,  and  sweet  cakes, 
he  is  kept  in  a  state  of  chronic  acid  dyspepsia  which  is  a  source  of  constant 
discomfort  to  himself  and  anxiety  to  his  friends.  The  whole  system  being 
full  of  acid  generated  by  fermenting  food,  the  child  is  wayward  and  cross 
in  temper,  and  excessively  fidgety  and  restless.  His  speech  is  often  hesi- 
tating, and  he  may  stammer  in  his  talk.  His  muscles  are  irritable  and 
twitch  easily,  so  that  he  winks  his  eyes  and  distorts  in  nervous  fashion  the 
corners  of  his  mouth.  The  so-caUed  nervous  habits  of  children  often  owe 
their  origin  to  this  derangement. 

Sickness  is  not  a  common  symptom  in  these  cases,  for  gastric  catarrh  is 
by  no  means  always  accompanied  by  irritability  of  stomach.  Sometimes, 
however,  the  child  at  rare  intervals  brings  up  a  large  quantity  of  sour-smell- 
ing fluid  and  mucus.  Frontal  headache,  more  or  less  severe,  is  rarely  ab- 
sent, and  oftentimes  the  pain  is  distressing.  The  wearing  periodical  head- 
aches of  children  are  not  uncommonly  owing  to  this  cause.  The  mine  is 
noticed  from  time  to  time  to  be  thick  with  hthates  ;  and,  in  rare  cases,  quan- 
tities of  fine  uric  acid  sand  are  passed,  precipitated  by  the  free  acid  with 
which  the  urine  is  charged. 

In  some  cases  a  curious  condition  of  the  ton<?ue  is  noticed.     On  the 


612  DISEASE   IIST   CHILDEEN. 

dorsum  are  seen  rounded  or  oval  patches,  wMch.  appear  to  consist  in  a  re- 
moval of  the  epithehal  covering.  The  surface  of  the  patches  is  distinctly 
depressed,  and  the  colour  is  that  of  the  dorsum  generally.  The  edges  are 
circumscribed  and  irregular.  The  number  of  these  patches  is  usually  thi'ee 
or  f  oiu\  They  may  be  seated  on  the  dorsum  or  on  the  edges  of  the  tongue. 
At  times,  small  rounded  ulcers  (aphthae)  and  red  elevated  papillae  are  seen  at 
the  tip  of  the  tongue  in  addition  to  the  dej)ressed  patches  on  the  dorsum. 
If  aphthiB  are  not  present,  there  is  no  pain  or  soreness. 

Symptoms  such  as  the  above  show  a  high  degree  of  digestive  derange- 
ment, aggravated  by  an  unsuitable  dietary,  and  are  almost  invariably  the 
consequence  of  repeated  attacks  of  catarrh  of  the  stomach.  Under  such 
circumstances,  nutrition  is  interfered  with,  the  child  wastes  perceptibly,  and 
the  apprehensions  of  the  parents  are  earned  to  a  high  degree.  ^Tien,  on 
the  other  hand,  the  indisposition  is  only  occasional,  and  the  symptoms  are 
not  severe,  httle  attention  is  excited.  The  child  is  supposed  to  be  a  bihous 
subject,  and  unless  the  attacks  become  so  frequent  as  to  cause  an  evident 
diminution  in  bulk,  or  some  new  symptom  is  noticed  which  excites  the 
alarm  of  the  friends,  medical  advice  is  considered  unnecessaiy. 

In  cases  where,  owing  to  the  mildness  or  infrequency  of  the  attacks  of 
gastric  derangement,  general  nutrition  has  not  suffered,  the  occiu'rence  of 
fainting  fits  may  induce  the  parents  to  apply  for  medical  assistance.  At- 
tacks of  syncope,  more  or  less  complete,  are  not  imcommon  in  these  cases. 
Naturally  enough,  they  give  rise  to  great  anxiety,  especially  if  conjoined 
with  palpitations  and  flatulent  pains  about  the  chest.  They  are  then  con- 
sidered to  be  symptomatic  of  heart  disease.  Thus,  a  little  girl,  aged 
eleven  years  and  a  half,"  fainted  for  the  fii'st  time  six  years  ago.  She  has 
since  fainted  on  five  different  occasions.  At  these  times  she  has  alwaj^s 
been  noticed  to  be  dull  and  languid,  with  a  poor  appetite,  but  otherwise 
has  seemed  to  be  well.  Is  subject  to  sharjD  pains  in  the  left  hypochon- 
drium,  under  the  influence  of  which  her  face  will  become  ghastly  white. 
She  sleeps  badly,  talking  and  moaning,  and  often  Hes  awake  at  night.  Has 
never  suffered  from  worms ;  bowels  are  confined.  Has  sometimes  a  sallow 
complexion."  This  young  lady,  who  was  a  well-gTown,  well-nouiished  girl, 
with  perfectly  sound  organs,  soon  lost  all  her  symptoms  under  suitable 
treatment. 

In  some  cases,  the  non-febrile  form  of  the  complaint  is  accompanied  by 
more  serious  symptoms.  There  may  be  severe  pain  in  the  epigastrium, 
violent  headache,  and  distressing  retching  and  vomiting,  first  of  food  and 
afterwards  of  bilious  or  watery  fluid.  Such  attacks  are  usually  soon  over. 
They  are  commonly  produced  by  the  introduction  of  some  mitant  into  the 
stomach,  and  cease  soon  after  the  complete  ejection  of  the  offending  mat- 
ters from  the  body.  For  some  days  afterwards  the  child  is  languid,  his 
digestion  weak,  and  vomiting  is  easily  excited. 

In  children  of  eight  or  nine  years  of  age  or  upwards,  the  dyspepsia  in- 
duced by  repeated  attacks  of  gastric  catarrh  may  give  rise  to  more  or  less 
severe  pain  after  food,  a  tendency  to  vomit,  pyrosis,  and  other  symptoms 
such  as  accompany  the  derangement  in  the  adult.  These  symptoms  are 
seldom  met  with  except  in  children  who  are  habitually  over-fed,  or  are  in- 
dulged with  rich  sauces  and  highly-spiced  and  stimulating  food.  They 
usually  quickly  subside  under  a  change  of  diet. 

Diagnosis. — The  febrile  form  of  acute  gastric  catarrh  often  presents 
some  difficulty  m  the  diagnosis,  for  the  symptoms  are  fi'equently  indefinite, 
and  the  case  may  be  mistaken  for  one  of  far  more  serious  disease.  Such 
cases  have  been  confounded  with  cases  of  acute  tuberculosis,  and  they  often 


GASTKIC   CATAEEH — DIAGNOSIS.  613 

present  a  strong  likeness  to  the  mild  form  of  enteric  fever.  The  prin- 
cipal points  upon  which  the  diagnosis  is  founded  will  be  best  illustrated 
by  the  narration  of  the  following  case  seen  in  consultation  with  Dr. 
G".iifcher. 

A  httle  girl,  aged  seven  years,  of  a  strumous  disposition,  had  been  deli- 
cate and  subject  to  occasional  failure  of  ajopetite  for  some  months.  For 
about  a  week  she  had  been  feverish,  the  bodily  temperature  rising  some- 
times as  high  as  104°  Fahr.  Her  appetite  had  been  completely  lost,  but 
she  had  not  suffered  from  sickness.  The  bowels,  at  first  sluggish,  had  been 
somewhat  relaxed  for  two  days,  the  motions  passed  being  moderate  in  quan- 
tity, but  loose,  rather  offensive,  and  bright  yellow  in  colour.  She  had  oc- 
casionally complained  of  abdominal  pains.  During  the  whole  time  of  her 
illness  the  child  had  snufiled  slightly,  and  at  first  her  throat  had  been  a 
little  sore,  but  there  had  been  no  cough.  She  had  complained  sometimes 
of  frontal  headache,  but  had  not  been  delirious. 

At  my  visit  I  found  the  child  lying  in  bed  with  her  face  turned  away 
from  the  window,  as  the  hght,  she  said,  hurt  her  eyes.  There  was  no  sal- 
lowness  of  complexion.  Her  expression  was  placid,  and  not  at  all  anxious  or 
distressed.  The  tongue  was  a  little  furred  on  the  dorsum,  and  rather  red 
at  the  tip  and  edges.  She  was  thirsty,  but  had  no  desire  for  food.  The 
abdomen  was  soft,  without  tenderness  or  distention.  The  spleen  was  very 
indistinctly  felt ;  it  seemed  to  be  shghtly  enlarged.  There  was  no  rash  of 
any  kind  on  the  body,  nor  any  oedema  of  the  legs.  The  urine  was  not  al- 
buminous. The  heart  sounds  were  healthy.  There  was  no  rhonchus,  nor 
any  other  abnormal  sign  about  the  lungs.  Respiration  regular,  24 ;  pulse 
regular,  108  ;  temperature,  101°  (at  4  p.m.). 

This  case,  which  was  seen  on  the  seventh  or  eighth  day  of  the  illness, 
when  the  ordinary  eruptive  fevers  could  be  excluded,  might  have  been 
acute  tuberculosis,  typhoid  fever,  or  acute  gastric  catai'rh.  The  occur- 
rence of  fever,  with  a  histoi-y  of  previous  delicacy  of  health,  was  quite  in 
keeping  with  the  ordinary  course  of  tuberculosis.  There  was,  however,  no 
family  history  of  any  such  complaint,  and  this  imj)ortant  fact,  together  with 
the  complete  absence  of  distress  or  anxiety  in  the  exj)ression  of  the  child, 
and  the  absence  also  of  any  oedema  of  the  extremities,  was  held  sufficient 
evidence  to  exclude  the  presence  of  this  formidable  disease. 

Between  typhoid  fever  and  acute  gastric  catarrh  the  distinction  was 
more  dif&cult.  The  temperature,  it  is  true,  although  always  elevated,  had 
not  followed  the  coui'se  of  the  temperature  in  a  tj^pical  case  of  enteric 
fever  ;  but  in  children  thisfev^er  is  often  mild,  and  frequently  deviates  from 
the  ordinary  type.  Again,  the  absence  of  eruption  did  not  exclude  typhoid 
fever,  for  the  eighth  day  is  early  for  the  rash  to  appear,  and  in  children  ty- 
phoid spots  are  sometimes  absent  altogether  in  undoubted  cases  of  the  dis- 
ease. On  the  other  hand,  the  state  of  the  spleen  was  doubtful.  Some 
slight  enlargement  was  suspected  ;  if  this  was  so,  the  fact  pointed  distinctly 
to  typhoid  fever. 

In  favour  of  acute  gastric  catarrh  was  the  slight  snuffling,  the  mild  sore 
throat,  the  complete  absence  of  delirium  or  of  apparent  discomfort,  and 
the  irregularity  of  the  fever.  Altogether,  the  symptoms  pointed,  perhaps, 
more  decidedly  to  gastric  catarrh  than  to  the  more  serious  disease,  but  ib 
was  impossible  to  exclude  t3q:)hoid  fever  ;  therefore,  a  guarded  opinion  was 
expressed  as  to  the  nature  of  the  case.  The  temperature  fell  on  the  follov>'- 
ing  (eighth  or  ninth)  day.  This  early  termination  seemed  to  decide  the 
question  in  favour  of  catarrh,  for  it  is  only  in  very  exceptional  cases  that 
typhoid  fever  subsides  before  the  fourteenth  day. 


614  DISEASE   TN.   CHILDREIS^. 

When  gastric  catarrh,  instead  of  occurring  in  one  sohtary  attack,  as  in 
the  above  instance,  recui's- repeatedly  at  short  intervals,  the  diagnosis  is 
raore  easy.  This  recurrent  form  is  well  illustrated  by  the  following  case 
which  was  sent  to  me  by  Dr.  Lister,  of  Croydon. 

A  httle  girl,  aged  seven  years,  paUid  m  aj)pearance  and  ill-grown,  had 
been  wasting  slowly  for  eighteen  months.  During  the  whole  of  this  time 
she  had  suffered  every  two  or  three  weeks  from  attacks  of  feverishness.  In 
these  illnesses  the  symptoms  were  the  same.  The  temperature  rose  to  103° 
and  104°.  The  child  looked  sallow  in  the  face,  and  was  very  irritable  and 
languid.  She  was  thirsty,  but  refused  her  food.  Sometimes  she  vomited, 
but  in  the  earher  attacks  the  bowels  were  never  relaxed.  She  got  thinner 
and  weaker,  and  looked  ill.  A  few  months  previous^  she  had  had  a  severe 
attack  at  Lowestoft,  in  which  she  had  been  slightly  jaiandiced.  Six  weeks 
♦before  her  visit  to  me  she  had  had  a  still  more  violent  attack,  which  had 
left  her  completely  jaundiced.  This  had  been  followed  for  the  first  time  in 
her  experience  by  diarrhoea ;  and  for  a  fortnight  the  motions  were  green 
and  slimy,  and  sometimes  contained  clots  of  blood.  They  were  passed 
with  straining  and  some  pain.  At  the  time  of  her  visit,  the  looseness  had 
in  a  great  measure  subsided,  but  the  child  still  had  a  faint  yellow  tint  of 
the  skin.  Her  heart  and  lungs  were  healthy,  and  there  was  no  sign  of  en- 
largement of  the  bronchial  glands.  Between  the  attacks  of  illness  the 
child  was  said,  as  a  rule,  to  be  fairly  well.  On  the  subsidence  of  the  fever 
her  appetite  would  return,  and  she  would  begin  to  regain  flesh.  Unfortu- 
nately, before  her  strength  could  be  said  to  be  thoroughly  restored,  it  would 
be  again  reduced  by  a  new  access  of  fever. 

Jaundice  in  children  after  the  period  of  infancy,  is,  in  the  large  majority 
of  cases,  catarrhal.  La  this  child,  its  occurrence  with  the  two  last  attacks  of 
fever  helped  greatly  to  explain  the  nature  of  these  attacks,  and  the  cause 
of  the  ill-health  from  which  the  child  was  suffering.  Moreover,  in  the 
most  recent  illness,  a  new  feature  had  been  noticed  in  the  diarrhoea  which 
had  followed  the  jaundice  and  still  further  delayed  convalescence.  In  this 
diarrhoea,  the  characters  of  the  stools,  Avhich  contained  mucus  and  blood,  and 
were  passed  with  straining  and  pain,  pointed  to  a  catarrh  of  the  lower 
bowel.  Explaining,  then,  the  earlier  attacks  in  the  light  afforded  by  the 
latter,  it  was  evident  that  the  child's  sensitiveness  to  changes  of  temperature 
showed  itself  in  the  form  of  repeated  attacks  of  acute  gastric  catarrh,  ac- 
companied by  fever.  This  fact  being  once  established,  the  treatment  of 
the  case  was  conducted  upon  the  principles  to  be  described,  and  the  child 
had  no  retru'n  of  her  feverish  symptoms. 

The  non-febrile  form  of  the  disease  may  be  recognised  without  difficulty. 
Frequently-recurring  attacks  of  indigestion,  a  tendency  to  acidity  and  flat- 
ulence, restlessness  and  irritability  after  indulgence  in  sweets  and  other 
forms  of  fermentable  food,  are  almost  invariably  the  consec[uence  of  gastric 
catarrh.  The  complaint  is  so  common  a  one  that  it  should  be  always  sus- 
pected in  children  who  are  habitually  pale,  thin,  and  nervous,  with  a  sallow 
complexion,  and  who  are  subject  periodicaUy  to  fits  of  irritability  and  ill- 
temper.  Continued  loss  of  appetite  from  this  cause  often  excites  appre- 
hensions that  the  child  is  becoming  consumptive.  The  real  cause  of  his 
wasting  may,  hoew^^er,  be  detected  by  noticing  that  the  chest,  on  examina- 
tion, shows  no  sign  of  disease  ;  that  his  expression,  although  occasionally 
wearied,  as  after  exei'tion  or  before  going  to  bed,  is  not  habitually  distressed, 
and  that  the  evening  temperature  is  normal.  On  inquiry,  too,  it  will  be 
found  that  the  wasting  is  not  a  constant  feature,  but  that  the  child  is 
better  and  worse,  sometimes  appearing  to  be  almost  well  and  to  gain  flesh ; 


GASTEIC    CATAEEH — TEEATMEISTT.  615 

at  others,  being  languid,  moping,  and  sallow-looking  when  indigestion  is 
excited  by  a  fresh  attack  of  catarrh. 

Treatment. — Whether  the  gastric  catarrh  assumes  the  febrile  or  the  non- 
febrile  form,  its  treatment  is  the  same.  Our  object  is,  firstly,  to  put  a  stop 
to  the  existing  derangement,  and,  secondly,  to  adopt  such  measures  as  will 
prevent  its  recurrence. 

To  cure  the  existing  catarrh,  we  must  do  our  best  to  remove  all  sources 
of  irritation  which  may  be  keeping  up  the  disorder.  The  acrid  mucus,  a 
free  secretion  of  which  is  one  of  the  ordinary  phenomena  of  the  catarrhal 
state,  is  a  constant  source  of  fermentation  and  acidity.  It  very  quickly  in- 
duces an  acid  change  in  the  more  fermentable  articles  of  food.  Therefore, 
if  the  stomach  be  oppressed  by  sour  matters,  shown  by  uneasiness  at  the 
epigastrium,  a  sour  smell  from  the  breath,  and  a  feeling  of  nausea,  im- 
mediate benefit  will  be  derived  from  an  emetic  dose  of  ipecacuanha  wine. 
Afterwards,  a  draught  composed  of  tincture  of  nux  vomica  (fit j.-iij.),  with 
bicarbonate  of  soda  (gr.  iv.-vi.),  in  water  sweetened  with  spirits  of  chloro- 
form, taken  two  or  three  times  a  day,  will  soon  restore  the  gastric  mucous 
membrane  to  a  healthy  condition.  Strong  purgatives  are  to  be  avoided, 
but  as  there  is  usually  constipation  in  these  cases,  an  occasional  mild  ape- 
rient will  be  required,  such  as  compound  liquorice  powder  or  castor-oil.  If 
there  be  fever  which  does  not  subside  after  the  action  of  the  emetic,  the 
child  may  be  allowed  to  take  fluids  from  time  to  time  in  moderate  quanti- 
ties. The  best  are  unsweetened  barley-water,  flavoured,  if  desired,  with 
orange-fiower-water,  and  fresh  whey. 

During  the  treatment,  as  long  as  any  signs  of  acidity  of  the  stomach 
persist,  care  should  be  taken  to  exclude  from  the  diet  all  matters  capable 
of  favouring  the  tendency  to  fermentation  of  food  ;  and  even  for  some  time 
afterwards,  readily  fermentable  substances,  such  as  starches  and  sweets, 
should  be  taken  sparingly,  lest  the  derangement  be  encouraged  to  return. 
At  first,  nothing  should  be  allowed  but  freshly-made  broths,  with  dry  toast, 
and  when  milk  is  once  more  permitted,  it  must  be  guarded  with  a  fourth 
part  of  lime-watei-,  or  with  saccharated  solution  of  lime,  in  the  jDroportion 
of  twenty  drops  to  the  teacupful.  While  the  derangement  continues,  no 
fruit,  cake,  sweets,  light  puddings,  or  potatoes  should  be  permitted.  When 
the  appetite  begins  to  return,  a  little  fish,  chicken,  or  mutton  may  be  al- 
lowed, but  the  child  must  not  be  pressed  to  eat ;  indeed,  until  his  diges- 
tive power  be  completely  restored,  the  utmost  care  must  be  taken  not  to 
overload  the  stomach  with  food. 

The  above  measures  will  effect  a  considerable  improvement  in  the  con- 
dition of  the  child,  but  at  this  point  the  treatment  may  be  said  only  to  have 
begun.  The  patient  is  in  a  weakly  state  fi-om  successive  attacks  of  gastric 
catarrh.  We  have  therefore  to  ado]3t  measures  to  strengthen  the  diges- 
tive power,  and  take  such  precautions  as  will  insure  him  against  a  relapse. 

To  give  tone  to  the  stomach  and  strengthen  digestive  power,  prepara- 
tions of  iron  are  required.  It  is  a  common  practice  in  such  cases  to  admin- 
ister the  jDreparation  of  the  phosphates  of  iron  and  hme  known  as  "  Par- 
rish's  chemical  food."  This  syrup  is  a  very  favourite  remedy  with  mothers, 
who,  misled;  perhaps,  by  the  name,  give  it  largely,  and  with  the  worst  results. 
Theoretically,  no  doubt,  it  is  an  active  tonic,  but  practically  it  is  highly  per- 
nicious. The  reason  is  that  the  syrup  in  which  the  phosphates  are  dissolved 
supphes  material  for  fermentation,  and  each  dose  is  soon  followed  by  acid- 
ity and  flatulence,  so  that  the  medicine  really  aggravates  the  mischief  it  is 
intended  to  allay.  The  better  plan  is  to  give  the  dialysed  iron,  or,  if  there 
be  any  tendency  to   acidity  remaining,  the  ammonio-citrate,  mth  a  few 


616  DISEASE  IjSr   CHILDREN. 

grains  of  bicarbonate  of  soda,  sweetened  witli  spirits  of  chloroform.  After 
a  time  a  change  may  be  made  to  the  solution  of  strychnia,  with  the  per- 
chloride  or  pemitrate  of  iron,  given  directly  after  food.  All  this  time,  the 
quantity  of  fermentable  material  taken  at  meals  much  be  restricted,  as  al- 
ready recommended.  Diu'ing  the  same  time,  a  mild  aperient  should 
be  given  every  few  days,  whether  it  seems  to  be  requii-ed  or  not,  to 
insure  proper  relief  to  the  bowels,  and  prevent  the  retention  of  any  excess 
of  mucous  secretion. 

In  sjDite  of  this  treatment,  however,  the  child  will  not  be  secui'e  against 
relaj)ses  unless  sjDccial  precautions  are  taken  to  guard  the  body  against 
chills.  The  catarrhal  state,  whatever  be  the  organ  affected,  tends  con- 
stantly to  repeat  itself  under  the  influence  of  slight  causes,  and  there  is 
little  doubt  that  it  induces  an  extreme  sensitiveness  to  changes  of  tempera- 
ture. Children  who  suffer  from  attacks  of  catarrh  of  the  stomach  and 
bowels,  should  wear  a  broad  flannel  bandage  applied  tightly  to  the  ab- 
domen, so  as  to  reach  from  the  hips  upwards  to  the  arm-pits ;  and  the 
medical  jDractitioner  should  look  upon  it  as  his  fii'st  duty  in  these  cases  to 
see  that  it  is  proj^erly  applied.  The  binder  should  be  considered  as  part 
of  the  child's  ordinary  da-ess,  and  be  cast  off  at  night  with  the  rest  of  his 
clothes.  In  many  cases  it  is  necessary,  in  addition  to  the  above  precautions, 
to  fortify  the  resisting  power  of  the  child  by  cold  batliing.  Some  caution, 
however,  is  often  required  in  recommending  this  step  to  parents.  Mothers 
are  apt  to  take  fright  at  the  very  mention  of  cold  water ;  and  it  is  true  that, 
in  the  case  of  weakly  children,  reaction  is  diiflcult  to  estabhsh,  so  that  a  cold 
bath  given  in  the  ordinary  way  would  not  be  attended  with  benefit.  If, 
however,  the  bath  be  given  according  to  the  method  advocated  on  a  pre- 
vious page  (see  page  17),  and  the  skin  be  first  stimulated  by  rigorous  fric- 
tion so  as  to  enable  the  body  to  resist  the  shock  of  the  cold  douche,  and 
the  shock  itself  be  lessened  by  making  the  child  sit  in  a  few  inches  of  hot 
water,  the  bath  viiG.  have  a  highly  inrigorating  effect  and  be  followed  by 
immediate  reaction.  The  continued  use  of  this  bath,  besides  having  a  re- 
markably tonic  effect  upon  the  system  generally,  confers  great  resisting 
power  against  changes  of  temperature,  and  considerably  reduces  the  child's 
susceptibility  to  chills. 

By  means  such  as  have  been  indicated,  the  most  obstinate  gastric  catarrh 
may  be  treated  with  success.  But  it  must  be  borne  in  mind  that  success 
depends  upon  equal  attention  to  all  the  points  that  have  been  insisted 
upon.  A  flannel  binder  will  be  of  little  value  if  the  tendency  to  fermenta- 
tion is  encoui'aged  by  the  immoderate  use  of  starches  and  sweets ;  and  even 
cold  douching  may  not  be  sufficient  to  neutralise  the  ill-effects  of  rajoid 
changes  of  temperature  acting  upon  a  body  imperfectly  protected  fi'om  the 
cold.  In  all  cases,  it  is  advisable  to  avoid  the  use  of  synips  in  making 
medicines  palatable  to  children.  The  pharmacopoeia  syrups  are  not  well 
borne  by  young  subjects,  and  often  do  more  harm  than  good.  It  is  far 
better  to  sweeten  the  child's  physic  with  glycerine,  or  a  few  drops  of  spirits 
of  chloroform. 

In  cases  where  habitual  pain  after  food  is  complained  of,  the  treatment 
found  useful  in  similar  cases  in  the  adult  should  be  resorted  to.  The  diet 
should  be  arranged  on  the  principles  already  indicated.  Both  sauces  and 
highly-spiced  or  fermentable  food  should  be  forbidden,  and  the  child 
should  take  bismuth  and  soda,  or  smaU  doses  of  dilute  hydrocyanic  acid 
with  an  alkali. 


CHAPTER  III. 

CONSTIPATION. 

Children  of  all  ages  are  subject  to  constipation.  Usually,  it  is  a  temporary 
derangement,  which  quickly  subsides  under  suitable  treatment.  In  other 
cases  it  amounts  to  a  positive  infirmity,  and  is  exceedingly  obstinate  and 
difficult  of  cure.  The  term  constipation  is  a  relative  one.  In  itself,  it  im- 
plies injury  to  the  health  fi-om  retention  in  the  alimentary  canal  of  matters 
which  ought  to  be  discharged.  The  condition  is  therefore  compatible  with 
a  daily  evacuation,  if  the  relief  afforded  to  the  system  is  incomplete.  In 
infants  who  require  the  bowels  to  be  emptied  several  times  in  the  day,  a 
single  stool  in  the  twenty-four  hours  is  a  sign  of  costiveness  which  should 
not  be  neglected. 

All  forms  of  mechanical  obstruction  to  the  passage  of  the  intestinal  con- 
tents give  rise  to  arrested  or  imperfect  evacuation  as  a  prominent  symptom. 
This  variety  of  constipation  is  not  here  referred  to.  The  form  under  con- 
sideration in  this  chapter  is  due  to  deficiency  of  expulsive  action,  and  not 
to  narrowing  of  the  channel,  or  other  kind  of  mechanical  hindrance. 

Causation. — One  of  the  commonest  causes  of  constipation  is  an  unsuit- 
able dietary.  This  is  esj)ecially  the  case  in  infants.  A  child  brought  up 
by  hand,  and  fed  with  excess  of  farinaceous  food,  is  often  troubled  with  an 
obstinate  form  of  costiveness  which  is  a  source  of  continual  discomfort. 
The  frequent  passage  along  the  bowels  of  undigested  starchy  matter  keeps 
the  mucous  membrane  in  a  state  of  constant  hyper-secretion.  A  slimy  mu- 
cus is  thrown  out  which  coats  the  lumps  of  undigested  food  so  that  the 
muscular  coat  of  the  bowel  in  its  contractions  can  have  little  hold  upon 
their  slippery  surface,  and  they  are  forced  forwards  with  difficulty. 

Still,  all  cases  of  constipation  occurring  in  hand-fed  babies  cannot  be 
attributed  to  this  cause.  Often,  the  most  careful  examination  of  the  stools 
can  detect  no  excess  of  mucus.  On  the  contrary,  the  motions  are  hard  and 
lumpy,  and  seem  to  be  drier  than  natural  This  very  cbyness  of  the  evacu- 
ations appears  in  many  cases  to  constitute  a  cause  of  infrequent  relief  to 
the  bowels.  We  know  from  cases  of  diabetes  in  the  adult,  where  the  ex- 
cessive drain  of  water  from  the  kidneys  diminishes  intestinal  secretion,  how 
commonly  constipation  results  from  this  want  of  moisture.  In  the  young 
child,  a  similar  deficiency  of  secretion,  however  induced,  may  cause  dryness 
of  the  fgecal  contents  and  diminish  the  facility  of  their  passage.  Special 
articles  of  diet  have  a  constipating  effect  upon  certain  children.  In  some, 
rice  interferes  with  the  regular  action  of  the  bowels.  In  others,  eggs  may 
induce  a  like  sluggishness.  I  have  known  troublesome  costiveness  continue 
as  long  as  the  yolk  of  an  egg  was  allowed  every  day,  and  disappear  at  once 
when  the  number  of  eggs  was  reduced  to  two  in  the  week. 

Atony  of  the  bowel,  or  actual  deficiency  of  expulsive  power,  is  a  not  un- 
common cause  of  constipation  even  in  young  subjects.  In  badly-noiu"ished 
children,  the  muscular  coat  of  the  intestine  must  share  in  the  general  mal- 


618  DISEASE  I]^r   CIIILDREjNT. 

nutrition;  and  as,  in  tliis  condition,  tlie  lower  part  of  the  colon  and  rectum 
are  apt  to  be  over-distended  by  accumulation  of  undigested  food,  the  diffi- 
culty of  carrying  forwards  the  fsecal  masses  is  increased.  In  some  cases,  the 
difficulty  is  added  to  by  a  peculiarity  of  infancy  upon  which  Dr.  Jacobi  has 
laid  much  stress  as  a  cause  of  constipation  in  very  early  life.  In  the  new- 
born infant,  the  length  of  the  large  gut  is  proportionately  greater  by  about 
one-third  than  it  is  in  the  adult.  This  excess  of  length  is  due,  not  to  the 
ascending  and  transverse  colon,  which  are  rather  shorter  at  this  age  than 
they  become  in  after  years,  but  to  the  descending  colon  and  sigmoid  tlexui-e. 
Consequently,  the  flexure  is  thrown  into  many  curves,  and  is  often  bent 
upon  itself  so  repeatedly  as  seriously  to  retard  the  passage  of  its  contents. 

Sluggishness  of  peristaltic  action,  if  not  comjolete  atony  of  the  bowel, 
may  be  a  sequence  of  certain  diseases.  After  chronic  diarrhoea,  a  state  of 
consti]3ation  commonly  prevails  which  is  very  difficult  of  cure.  Typhoid 
fever  often  leaves  a  similar  condition  behind  it,  and  after  an  attack  of  acute 
rheumatism  the  same  inactivity  of  the  bowels  is  often  noticed.  Again,  ul- 
ceration of  the  intestinal  mucous  membrane,  when  not  accompanied  by  ca- 
tarrh, almost  invariably  induces  deficient  fsecal  excretion,  and  sometimes,  in 
these  cases,  excrementitial  matters  may  be  long  retained.  In  typhoid  fever, 
constipation  of  a  week  or  longer  is  frequentty  met  with,  and  indeed,  in  many 
cases,  no  effort  at  expulsion  appears  to  be  made  until  the  bowels  are  excited 
to  contract  by  a  copious  enema.  In  these  cases,  no  doubt,  the  normal  pe- 
ristaltic action  of  the  bowels  at  the  seat  of  ulceration  is  paralysed  by  the 
inflammatory  process  there  existing ;  but  a  similar  sluggishness  of  the  in- 
testinal mucous  membrane  may  be  induced  by  disease  in  a  distant  part  of 
the  body.  Thus,  disease  of  the  brain  or  its  membranes  is  usually  accom- 
panied by  constipation  as  a  prominent  symptom,  and  in  another  part  of 
this  volume  reasons  are  given  for  supposing  that  Bright's  disease  in  the 
young  child  may  produce  the  same  result. 

There  is  one  cause  of  constij)ation  in  infants  which  must  not  be  for- 
gotten. This  is  the  sluggishness  of  the  bowels  which  is  induced  by  opium. 
Hand-fed  babies  are  apt  to  be  very  peevish  and  troublesome  at  night,  and 
an  unscrupulous  nurse  will  often  drug  the  child  with  "  soothing  syrup  "  or 
other  opiate  in  order  that  her  own  sleep  may  be  undisturbed.  This  prac- 
tice induces  a  very  obstinate  form  of  constipation,  and,  unless  detected,  may 
be  a  cause  of  much  perplexity  to  the  medical  attendant.  It  is  therefore 
important  in  obstinate  cases  to  examine  the  child's  pupils. 

The  causes  which  have  been  referred  to  may  influence  the  state  of  the 
bowels  at  aU  periods  of  childhood,  but  there  are  other  causes  which  largely 
prevail  after  the  period  of  infancy  has  passed.  Habitual  neglect  of  the 
calls  of  nature  is  as  common  a  cause  of  constipation  in  young  people  as  it 
is  in  their  elders.  The  lower  bowel,  when  it  finds  its  warnings  neglected, 
soon  becomes  accustomed  to  the  presence  of  its  faecal  contents,  and  requires 
something  more  than  the  ordinary  stimulus  to  excite  its  action.  Whether 
from  necessity  or  convenience,  school-children  of  both  Sexes  often  suppress 
the  natural  desire  for  relief ;  but  if  the  favourable  moment  is  allowed  to 
pass,  efforts  made  at  another  time  are  often  inefiectual,  and  a  habit  of  con- 
stipation is  thus  acquired  which  may  be  very  difficult  to  overcome.  Even 
during  infancy,  constipation  may  be  made  worse  by  this  means.  Children 
of  ten  or  twelve  months  old,  who  have  been  subjected  to  much  pain  from 
distention  of  the  sphincter  by  hard  faecal  masses,  will  often  resist,  as  long 
as  possible,  the  desu-e  to  empty  the  bowel,  in  order  to  spare  themselves  un- 
necessary suffering.  In  such  cases,  if  measm-es  are  not  taken  to  enforce  due 
evacuation,  serious  accumulation  may  ensue. 


CONSTIPATION — SYMPTOMS.  619 

Want  of  exercise  is  another  cause  which  is  often  found  to  prevail 
amongst  young  girls,  especially  if  they  are  much  confined  to  the  house  and 
pressed  too  quickly  forward  in  their  studies,  and  very  obstinate  constipation 
may  result  from  their  sedentary  life. 

Symptoms. — In  infancy,  deficient  excretion  from  the  bowels  is  usually 
indicated  by  a  pasty,  dull  complexion,  fretfulness,  and  agitation,  especially 
at  night.  The  child's  sleep  is  not  the  sound,  unbroken  sleep  of  health.  He 
often  starts  and  twitches,  and  is  roused  up  by  the  least  noise.  Flatulence 
is  an  early  consequence.  The  child  seems  to  suffer  from  occasional  twinges 
of  pain,  for  he  often  ci-ies  suddenly  without  evident  cause,  and  draws  up  his 
lower  limbs  uneasily.  His  upper  lip  looks  purple  ;  the  muscles  of  his  mouth 
twitch,  and  if  the  pain  is  severe,  his  whole  complexion  ma}^  become  ghastly 
white.  If  the  constipation  is  obstinate,  the  stools  are  voided  with  great  diffi- 
culty ;  and  in  cases  where  several  days  pass  without  any  relief,  defecation  is 
only  effected  with  much  straining  and  pain.  The  infant  often  makes  violent 
efforts  to  unload  his  bowel  of  its  accumulated  burden,  and  wiU  strain  until 
his  face  is  purple,  his  bowel  prolapses,  and  his  navel  starts.  Tinging  of  the 
faecal  masses  with  blood  from  rupture  of  small  vessels  about  the  anus  is  often 
seen,  and  umbilical  hernia  not  unfrequently  owes  its  origin  to  this  cause. 

The  belly  is  generally  swollen  from  flatulence,  and  sometimes  the  gas 
accumulates  in  such  quantity  as  to  cause  a  fit  of  violent  colic,  in  which  the 
child  gives  signs  of  extreme  suffering,  screaming  and  writhing  and  draw- 
ing up  his  legs.  Actual  convulsions  may  be  induced  by  this  cause.  In 
cases  where  irritation  of  the  bowels  is  excited  by  the  retention  of  excremen- 
titial  matters,  the  temperature  may  become  elevated  for  a  time,  but  it  sub- 
sides at  once  when  the  accumulation  has  been  removed.  In  many  children, 
the  torpor  of  the  bowel  is  accompanied  by  languid  circulation,  so  that  the 
hands  and  feet  are  habitually  cold.  If  the  state  of  constij)ation  continue, 
the  general  health  usually  suffers  ;  the  flesh  gets  flabby,  and  the  child  is 
peevish  and  fretful,  with  a  tendency  to  vomit.  Palpation  of  the  abdomen  will 
often  discover  hard  masses  in  the  descending  colon.  These  are  well-defined 
lumps,  are  painless,  and  can  be  indented  by  firm  pressm-e  with  the  finger. 

In  older  children,  we  see  httle  more  than  dulness  of  complexion,  a  fuiTcd 
tongue,  and  some  want  of  sprightliness  and  activity.  The  child  may  com- 
plain of  discomfort  after  food  and  of  occasional  headaches.  His  breath  is 
often  unpleasant,  and  there  may  be  aphthae  on  the  tongue  and  lips,  or  red 
patches  on  the  tongue  from  which  the  epithelium  appears  to  have  been 
thrown  off.  Sometimes  the  bowels  act  only  at  rare  intervals,  and  if  projoer 
measures  are  not  resorted  to,  may  remain  confined  for  a  week  together,  or 
even  longer.  Such  children  are  subject  to  sick-headaches,  and  have  habit- 
ually a  pasty-looking,  unhealthy  tint  of  skin. 

If  the  constipation  proceed  to  actual  impaction  of  fsecal  masses  in  the 
bowel,  more  striking  symptoms  are  noticed.  The  impaction  usually  takes 
place  in  the  rectum  itself",  and  consists  of  a  quantity  of  hard  lumj)s  which 
it  is  very  difficult  to  break  down  and  bring  away.  The  presence  of  the 
hard  masses  causes  irritation,  which  shows  itself  by  more  or  less  pain  in 
the  lower  part  of  the  belly,  by  tenesmus,  and  often  by  difficulty  of  micturi- 
tion. The  child  is  generally  sallow,  listless,  and  weakly-looking.  The  appe- 
tite may  be  unaltered,  but  is  usually  poor.  The  tongue  is  often  quite  clean, 
although  the  breath  is  foetid.  The  belly  is  distended  and  sometimes  tender. 
Diarrhoea  may  be  a  consequence  of  the  intestinal  irritation.  The  motions 
are  scanty  and  thin  ;  they  usualh'  contain  a  few  small  scybala,  and  are 
passed  with  much  jDain  and  tenesmus.  Instead  of  loose,  they  may  be  very 
small  and  solid,  with  excess  of  mucus. 


620  DISEASE   I]sr   CHILDREIS'. 

Ill  some  cases,  in  addition  to  irritation,  positive  injiu'y  may  be  caused  by 
the  presence  of  the  faecal  masses.  Dr.  T.  Chambers  has  reported  the  case 
of  a  gii'l,  aged  eleven  yeai's,  who  had  suffered  for  three  months  from  a  per- 
sistent diarrhoea  which  was  the  consequence  of  a  vast  accumulation  of  faeces 
in  the  rectum.  The  mass  by  its  pressure  had  caused  absorption  of  the 
triangular  cushion  which  constitutes  the  perinseum,  and  had  reduced  the 
recto-vaginal  septum  to  a  mere  membrane. 

These  cases,  if  not  judiciously  treated,  may  actually  prove  fatal.  Dr. 
Bristowe  has  referred  to  the  case  of  a  little  gii'l,  eight  years  old,  who  had 
long  suffered  from  a  tendency  to  constipation,  and  had  occasionally  gone  for 
three  weeks  without  relief  to  the  bowels.  When  she  came  under  observa- 
tion she  had  had  no  passage  for  seven  w^eeks.  The  cliild  was  pale  and  thin, 
with  a  strumous  look.  Her  belly  was  large  and  tense,  although  painless, 
her  tongue  clean  and  her  apjDetite  poor.  She  grew  weaker,  and  looked  hag- 
gard and  anxious.  Her  belly  became  more  distended,  and  occasional  colicky 
pains  were  complained  of.  Towards  the  end,  her  tongue  became  foul ;  she 
often  vomited,  passed  high-coloured  urine  in  small  quantity,  and  eventually 
sank  from  exhaustion.  The  vomiting  was  never  stercoraceous.  After  death, 
the  intestines  were  found  greatly  distended  and  their  coats  hypertrophied. 
They  were  full  of  olive-gi"een,  semi-solid  fseces,  which  were  of  thicker  con- 
sistence in  the  rectum  than  elsewhere  ;  and  immediately  above  the  anus 
w^as  a  hard  conical  plug  of  fsecal  matter  which  completely  prevented  the 
escape  of  the  contents  of  the  bowel. 

If  impaction  take  place  at  a  higher  point  in  the  bowel — in  the  csecum 
or  at  a  bend  of  the  colon — symptoms  of  complete  occlusion  may  arise, 
and  inflammation  is  often  excited  in  the  intestine.  Over  the  seat  of  ob- 
struction there  is  pain,  which  may  extend  to  the  whole  abdomen,  and  be 
violent  and  paroxysmal ;  there  is  tenesmus,  and  the  bowels  are  obstinately 
confined.  The  child  vomits  repeatedly,  throwing  up  at  first  bile  and  mu- 
cus, afterwards  feculent  matter.  Hiccough  may  be  distressing.  The  abdo- 
men is  distended.  The  tongue  is  thickly  fiu-red,  and  perhaps  dry  and 
brown.  The  pulse  is  rapid,  small,  and  thready ;  the  temperature  is  often 
high,  and  the  prostration  is  extreme.  On  examination  of  the  belly,  a  hard 
swelling  may  be  detected  through  the  muscular  wall,  and  can  often  be 
indented  with  the  finger ;  or,  if  inflammation  have  occui'red,  there  is  some 
tension  of  the  parietes,  and  an  intensely  tender  swelling  can  be  discovered 
at  the  seat  of  obstruction.  Inflammation  of  the  caecum  (typhhtis)  is  the 
naost  familiar  instance  of  this  inflammatory  form  of  the  disorder.  Firm 
impaction  of  the  colon  with  fseces  is  a  variety  of  obstruction  which,  if  not 
relieved  by  the  adoption  of  suitable  measures,  may  be  as  fatal  to  the  pa- 
tient as  any  other  form  of  intestinal  occlusion,  but  it  is  eminently  cui'a- 
ble  if  the  nature  of  the  impediment  be  recogTiised  in  time. 

Diagnosis. — In  ordinary  cases,  the  want  of  regularity  in  defecation,  and 
the  infrequent  passage  of  hard,  scanty  stools,  is  a  sufficient  token  of  the  ex- 
istence of  constipation.  But  often  the  indications  are  much  less  precise. 
In  infancy,  as  has  ah'eady  been  remarked,  a  single  stool  in  the  foui'-and- 
twenty  hours  constitutes  a  state  of  constipation  which  requires  attention. 
Even  in  older  cliildren  a  daily  evacuation  may  occur  and  yet  the  rehef  to 
the  bowels  be  incomplete.  Habitual  sallowness  of  complexion,  offensive 
breath,  wakefulness  at  night  and  startings  in  sleep,  are  common  indica- 
tions of  a  loaded  bowel,  esj)ecially  if  the  symptoms  occur  in  a  well-noui'ished 
child  who  presents  no  other  indication  of  ill-health ;  and  dysj)eptic  symptoms 
(discomfort  and  a  feeling  of  heaviness  after  meals,  occasional  nausea  and  a 
furred  tongue)  will  often  be  found  to  arise  from  the  same  condition. 


COTirSTIPATION — DIAGNOSIS — TEEATMENT.  621 

It  is  very  important  in  cases  where  the  evacuations  are  very  small,  fre- 
quent, and  watery,  or  loose,  to  remember  that  this  condition  is  often  a 
consequence  of  the  accumulation  of  fsecal  masses  in  the  rectum.  In 
such  cases,  we  may  expect  to  find  distention  of  the  beUy  and  tenesmus, 
with  some  pain  in  the  lower  bowel  in  defecation  ;  and  the  stools,  on  inspec- 
tion, will  be  found  to  consist  of  offensive,  thin  feculent  matter  containing 
mucus  and  a  few  small,  hard  scybalse.  When  these  symptoms  are  noticed 
in  a  child  of  four  or  five  years  of  age  or  upwards,  it  is  of  importance  to 
examine  the  rectum  ;  and  often  by  this  means  the  cause  of  the  apparent 
looseness  may  be  discovered  at  once.  Still,  even  if  we  obtain  evidence  of 
fsecal  accumulation,  caution  is  often  necessary.  We  must  not  at  once  con- 
clude that  retained  fsecal  matter  constitutes  the  whole  of  the  derangement, 
and  that  Avhen  this  has  been  removed  the  child  will  be  well.  Ulceration  of 
the  bowels  is  often  accompanied  by  this  Yery  group  of  symptoms.  This 
subject  is  considered  elsewhere  (see  page  661). 

If  actual  impaction  of  faeces  occur  so  as  to  offer  an  insuperable  obstacle 
at  any  point  of  the  intestinal  canal,  symptoms  of  occlusion  of  the  bowel 
arise.  The  distinction  between  this  condition  and  intussusception  is  ex- 
plained in  the  chapter  treating  of  the  latter  subject. 

Treatment. — The  regular  action  of  the  bowels  is  at  all  ages  so  much  a 
matter  of  habit  that  the  child  as  soon  as  he  can  walk,  or  even  earher, 
should  be  trained  to  regularity  in  this  important  particular.  Every  morn- 
ing after  breakfast  he  should  be  accustomed  to  go  punctually  to  stool,  and 
nothing  should  be  allowed  to  interfere  with  this  necessary  duty.  By  this 
means  the  bowels  become  accustomed  to  regular  relief  at  the  same  period 
of  the  day.  The  mother  should  herself  see  that  the  rule  is  enforced,  for  an 
inattentive  nurse,  from  ignorance  or  carelessness,  is  very  apt  to  neglect  it. 

In  infants,  constipation  may  be  combated  by  careful  regimen,  by  the 
adoption  of  special  articles  of  diet,  by  enemata,  and  by  drugs.  In  the  first 
place,  the  dietary  should  be  revised  and  excess  of  starchy  matter  excluded. 
If  the  child  is  eight  or  ten  months  old,  the  first  meal  in  the  day  may  con- 
sist of  a  teaspoonful  of  fine  oatmeal  rubbed  up  carefully  with  cold  mUk 
into  a  thin,  smooth  paste,  and  then  stirred  briskly  while  hot  milk  is  added. 
MeUin's  "  Food  for  Infants,"  probably  on  account  of  the  glucose  it  contains, 
often  has  an  admirable  effect  in  regulating  the  bowels  of  infants  wKo  are 
inclined  to  costiveness,  and  is  a  very  useful  resource.  If  the  constipation 
is  only  temporary  and  occasional,  a  small  lump  of  manna  dissolved  in  a 
dessert-spoonful  of  warm  water,  strained  and  added  to  the  bottle  of  food, 
has  a  ready  aperient  effect ;  or  fifteen  to  twenty  drops  of  the  liquid  extract 
of  rhamnus  frangula  will  be  equally  successful.  In  cases  where  the  consti- 
pation is  habitual,  I  have  found  a  combination  of  the  infusions  of  senna 
and  gentian  a  remedy  of  unfailing  usefulness.  I  usually  combine  these  with 
the  tinctures  of  belladonna  and  nux  vomica,  as  in  the  following  draught.  The 
quantity  ordered  is  suitable  to  a  child  between  eight  and  twelve  months  of  age, 
and  can  be  given  at  first  three  times  in  the  day  immediately  before  a  meal : — 

]J.  Tinct.  nucis  vomicae TTL  ss. 

Tinct.  belladonnsB "n],  v. 

Infusi  sennsB TTl  xx. 

Infusum  gentiansB  comp ad.   3  j- 

M.   Ft.  haustus. 
The  value  of  this  remedy  consists  in  the  fact  that  the  patient  does  not  be- 
come dependent  upon  the  medicine.     On  the  contrary,  it  has  a  strength- 
ening effect  upon  the  coats  of  the  bowel,  so  that  after  a  time  it  can  be  given 
twice  in  the  day,  then  only  once,  and  eventually  be  discontinued  altogether. 


622  DISEASE   IX   CHILDKEX. 

The  extract  of  malt,  on  account  of  its  glucose,  is  also  useful  in  relievmg 
the  constipation  of  infants  ;  but  must  be  given  in  sufficient  quantity,  i.e.,  a 
teasx^oonful  two  or  thi-ee  times  a  day.  It  is,  however,  very  inferior  to  the 
senna  mixture,  and  has  the  disadvantage  that  in  wai'm  weather  it  is  apt  to 
turn  acid  on  the  stomach  and  cause  nausea.  In  all  cases  of  habitual  con- 
stipation in  infants,  the  belly  should  be  rubbed  firmly  -nith  the  hand  twice 
a  day  after  the  bath,  so  as  to  stimulate  the  peristaltic  movement  of  the  bow- 
els. In  obstinate  cases.  Dr.  Meniman  advises  the  friction  to  be  made  with 
a  liniment  composed  of  half  an  ounce  of  the  tinctiu'e  of  aloes  to  one  ounce 
of  the  compound  soap  hniment.  Professor  Stephenson,  in  an  interesting 
jDaper,  has  proposed  the  use  of  pepsin,  in  cases  of  habitual  constipation,  for 
children  of  all  ages.  To  a  child  of  twelve  months  old,  three  gTains  of  the 
di'y  powder,  or  five  drops  of  pepsin  wine  may  be  given  three  times  a  day.  The 
remedy  must  be  taken  for  several  weeks,  and  can  then  be  gradually  discon- 
tinued. If  necessary,  an  occasional  dose  of  castor-oil  can  be  given  during 
the  tu'st  few  days  of  taking  the  pepsin,  but  this  is  seldom  required  to  be 
rejpeated  more  than  twice. 

The  above  methods  of  treatment  ai'e  greatly  to  be  preferred  in  cases  of 
habitual  constipation  to  the  mechanical  relief  of  the  bowels  obtained  by 
means  of  enemata,  or  even  by  the  use  of  suppositories.  Suppositories  of  Cas- 
tile soap,  cocoa  butter,  or  brown  gelatine  have  been  strongly  advocated  by 
some  wi'iters.  They  are  no  doubt  iisef  ul  in  produciug  an  immediate  effect, 
but  have  no  further  influence,  and  cannot  promote  healthy  and  regular 
action  in  the  future.  Enemata  are  of  service  in  unloading  the  bowels  where 
there  is  accumulation  of  fsecal  matter,  esjDecially  where  irritation  and  colie 
have  been  excited  by  its  retention.  They  should  be  composed  of  thin  gruel 
or  soap  and  water,  should  be  used  warm,  and  if  the  constipation  be  obstinate 
or  the  pain  severe,  may  contain  the  addition  of  a  spoonful  of  castor-oil. 
Care  should  be  taken  to  use  a  sufiicient  quantity  of  fluid.  An  enema  to  be 
effectual  in  such  a  case  should  consist  of  at  least  two-thuxls  of  a  pint  for  a 
child  of  six  months  old.  If  enemata  are  given  daily  to  reheve  habitual  con- 
stij)ation,  the  quantity  need  not  be  so  considerable.  Four  or  five  ounces 
wOl  usually  be  sufficient,  and  jDlain  water  of  the  temperatui-e  of  60°  Fahr. 
may  t)e  employed.  This  daily  repetition  of.  enemata  is  not,  however,  apian 
of  treatment  to  be  recommended. 

In  the  case  of  severe  cohc  in  a  baby,  flannels  wrung  out  of  hot  water 
should  be  applied  to  the  beUy,  and  a  copious  injection  of  warm  soap  and 
water,  with  or  without  the  addition  of  a  teaspoonful  of  castor-oil,  should 
be  administered  without  delay.  If  the  infant  seem  depressed  as  a  conse- 
quence of  the  pain,  he  may  be  given  a  few  drops  of  pale  brandy  in  a  tea- 
spoonful  of  water,  or  may  take  three  or  four  di'ops  of  sal  volatile  in  a  little 
aromatic  water  every  few  houi's.  If  there  be  twitching,  or  any  sigh  of 
con-sTilsions,  the  child  should  be  placed  at  once  in  a  warm  bath.  If  he 
suffer  much  from  flatulence,  a  rhubarb  and  soda  powder  may  be  adminis- 
tered, and  afterwards  a  teasjDOOnful  of  the  following  mixture  eveiy  three  or 
four  hours  : — 

I^ .  Tinct.  rhei 3  ss. 

Spirit,  chloroformi, 

Spuit.  ammon.  aromat aa.  TT],  xxiv. 

Glycerini 3  ij- 

Aquam  carui ad.  §  j. 

M.   Ft.  mistura. 

This  may  be  given  to  a  child  of  six  months  old. 


CONSTIPATIOjST — TREATMENT.  623 

In  cliildren,  after  the  age  of  infancy,  constipation  must  be  treated  by 
attention  to  diet,  and  by  the  enforcement  of  regular  habits.  The  diet 
should  be  carefully  selected  with  regard  to  its  digestibility,  avoiding  ex- 
cess of  farinaceous  and  saccharine  articles.  Well-made  oatmeal  porridge 
is  serviceable  at  breakfast,  and  broiled  bacon  at  this  meal  is  not  only  diges- 
tible but  useful.  With  his  dinner  the  child  may  take  a  sufficiency  of  fresh 
vegetables  and  fruits,  especially  baked  apples.  All  children  should  be 
cautioned  against  resisting  the  desire  to  empty  the  bowel,  and  should  be 
taught  regularity  in  this  respect,  as  has  been  already  recommended. 

As  an  occasional  aperient,  the  compound  liquorice  powder  (a  teaspoon- 
ful  mixed  with  a  small  quantity  of  water  or  milk  at  bedtime)  is  very  use- 
ful, and  much  more  to  be  recommended  than  the  syrup  of  senna  and  other 
saccharine  laxatives,  which  tend  to  promote  acidity  and  flatulence.  If  the 
constipation  is  habitual,  it  must  be  treated  after  the  manner  followed  in 
the  case  of  an  adult  patient.  The  senna  mixture  recommended  above  for 
babies  is  useful  given  in  suitable  doses.  If  the  child  can  take  a  pill,  Sir 
Andrew  Clark's  prescription  of  small  doses  of  podophyllin  and  extract  of 
belladonna  (one-sixth  of  a  grain  of  each  taken  at  bedtime)  will  usually, 
after  a  short  time,  produce  a  regular  daily  movement  ;  or  two  grains  of 
the  exsiccated  s alpha te  of  iron,  with  three  grains  of  the  aloes  and  myri'h 
l^ill,  taken  every  night  or  on  alternate  nights,  will  effect  the  same  object. 
In  cases  where  the  scanty  stools  consist  of  hard,  dry  lumps,  a  nightly  dose 
of  Hunyadi  Janos  water  (one  to  two  ounces)  will  quickly  produce  a  complete 
change  in  the  character  of  the  evacuations,  and  promote  a  daily  action  of  the 
bowels.     In  ail  these  cases,  regular  exercise  is  of  the  utmost  importance. 

If  impaction  of  fseces  in  the  bowel  be  complete,  the  treatment  will  vary 
according  as  to  whether  inflammation  have  or  have  not  been  excited  in  the 
intestine.  If  inflammation  have  occurred,  the  case  must  be  treated  as  de- 
scribed in  the  chapter  on  tyj)hhtis.  If  there  be  no  inflammation,  but  the 
bowels  are  merely  blocked  by  the  accumulated  scybalas,  it  is  usually  in  the 
sigmoid  flexure  or  rectum  that  the  collection  of  f;iBcal  matters  has  taken 
place.  In  such  cases,  the  persevering  use  of  purgative  enemata  will  event- 
ually relieve  the  patient.  The  difficulty  commonly  is  that  the  solid  plug 
often  prevents  the  passage  upwards  of  the  fluid,  so  that  this  returns  at  once 
by  the  side  of  the  tube  and  escapes.  If  the  impacted  mass  is  within  reach 
of  the  finger,  it  may  usually  be  broken  up  by  the  use  of  a  metalhc  sound. 
In  a  private  house,  a  marrow-spoon,  or  even  the  handle  of  an  ordinary 
spoon  of  suitable  size,  may  be  used  for  the  purpose.  In  giving  the  injec- 
tion, the  tube  of  the  enema  syringe  should  be  wrapped  round  with  lint  at 
its  base,  and  this,  after  introduction,  should  be  firmly  pressed  against  the 
anus  so  as  to  resist  the  escape  of  the  fluid.  A  large  quantity  of  thin  warm 
gruel,  with  an  ounce  of  castor-oil  and  half  an  ounce  of  turiDentine,  must  be 
injected  very  slowly,  and  the  patient  should  be  instructed  to  retain  it  as 
long  as  possible.  In  some  cases,  especially  if  the  impacting  mass  is  out 
of  reach  from  the  anus,  the  solid  plug  may  resist  repeated  enemata.  In  a 
case  recorded  by  Mr.  Gay — a  boy  of  seven  years  old  who  had  suffered  from 
complete  stoppage  of  the  bowels  for  three  months — the  constipation  was 
eventually  overcome  by  introducing  a  speculum  into  the  rectum,  so  as  to 
dilate  the  sphinctei',  and  then  directing  a  stream  of  water  against  the  ob- 
stacle. By  this  means,  after  the  stream  had  played  for  half  an  hour  or  more 
against  the  mass,  the  latter  became  disintegrated,  and  a  quantity  of  hard 
matter  like  cinders  was  brought  away,  to  the  great  rehef  of  the  patient. 

After  the  removal  of  the  accumulated  fseces,  it  is  very  important  to  keep 
the  bowels  regular  for  the  future  by  the  means  which  have  been  described. 


CHAPTEK  lY. 

DIARRHCEA. 

DiAEEHCEA  in  early  life  is  a  subject  of  the  utmost  importance,  as  to  it  a 
large  proportion  of  the  deaths  which  occur  in  infancy  are  to  be  ascribed. 
The  term  itself  is  a  vague  one.  It  expresses  merely  an  injurious  increase 
in  the  alvine  dejections,  without  reference  to  cause,  and  is  applied  equally 
to  a  trifling  derangement,  and  to  a  serious,  or  even  fatal  illness.  It  there- 
fore embraces  several  varieties  of  intestinal  disorder  which  are  chnicaUy 
distinct,  although,  anatomically,  perhaps,  they  may  present  mere  differences 
in  degree  of  the  same  pathological  condition.  For  practical  purposes  it 
will  be  convenient  to  describe  three  forms  of  bowel  complaint.  Simple 
non-inflammatory  diarrhoea  (mild  intestinal  catarrh)  ;  acute  inflammatory 
diarrhoea  (severe  intestinal  catarrh,  or  entero-colitis),  and  choleraic  diarrhoea 
(infantile  cholera).  Of  these,  the  first  only  will  be  treated  of  in  the  present 
chaptei'. 

In  simple  non-infiammatory  diarrhoea,  the  mucous  membrane  of  the  bow- 
els is  in  a  state  of  temporary  irritation,  restdting  from  a  mild  form  of  catarrh. 
The  disorder  is  a  mere  derangement  of  function,  is,  as  a  rule,  accompanied 
by  no  great  violence  of  purging,  and  is  quickly  arrested  by  suitable  treat- 
ment. By  many  writers,  this  form  of  diarrhoea  is  not  separated  from  the 
more  severe  variety  of  muco-enteritis,  which  will  be  described  afterwards. 
Its  clinical  characters  are,  however,  so  different,  and  its  symptoms  so  much 
less  serious,  that  it  is  convenient  to  devote  a  special  chapter  to  its  con- 
sideration. 

Causation. — Improper  feeding  is  one  of  the  most  frequent  causes  of 
looseness  of  the  bowels.  Amongst  hand-fed  babies,  the  disorder  is  especi- 
ally common,  and  unless  quickly  arrested,  is  very  apt  to  run  on  into  the  in- 
flammatory form,  and  prove  serious.  The  food  may  be  excessive  in  quantity, 
or  unsuitable  in  quality.  Often  it  is  both,  and  an  infant  of  a  few  months 
old  is  supplied  with  an  amount  of  farinaceous  food  far  in  excess  of  his 
powers  of  digestion.  The  food  is  consequently  carried  along  the  alimen- 
tary canal,  fermenting  and  irritating  the  mucous  surface  over  which  it 
passes,  until  it  is  discharged.  A  common  cause  of  looseness  of  the  bowels, 
is  the  practice,  which  often  prevails  in  badly-regulated  nurseries,  of  pre- 
paring for  the  infant  in  the  morning  the  whole  day's  supply  of  food.  The 
mixture  of  milk  and  sweetened  farinaceous  matter  seldom  remains  un- 
changed for  many  hours  together,  and  often,  after  a  short  time,  is  quite 
unfit  for  the  child's  consumption.  But  besides  infants,  children  of  all  ages 
are  subject  to  temporary  looseness  of  the  bowels,  from  the  irritation  of  un- 
digested and  fermenting  food.  Li  such  cases,  the  alvine  flow  may  be  re- 
garded as  the  natural  effort  of  the  bowel  to  relieve  itself  of  an  unwelcome 
burden.      The  danger  is,  that  in  infants,  and  weakly  children,  the  mild 


DIAREH(EA — CAUSATION — SYMPTOMS.  625 

catarrhal  process  may  not  cease  with  the  expulsion  of  the  offending  sub- 
stance, but  may  pass  on  into  the  more  serious  form. 

A  cause  which  is  little  less  common  than  the  above,  is  chilling  of  the  sur- 
face. Children,  and  especially  young  babies,  are  very  sensitive  to  changes 
of  temperature,  and  part  with  their  heat  very  rapidly.  Unfortunately,  it  is 
at  this  susceptible  age  that  the  body  is  habitually  less  cijyered  than  at  any 
other  period  of  life.  From  the  time  that  the  child  relinquishes  his  first 
long  clothes,  until  his  third  or  fourth  year,  he  is  exposed,  with  insufficient 
protection,  to  frequent  changes  of  temperature.  At  all  seasons,  while  in- 
doors, his  legs  and  arms  are  bare — often  his  neck  and  shoulders  as  well ; 
and  not  seldom  from  the  waist  downwards  he  is  covered  by  nothing  but  his 
short  and  scanty  skirts.  It  is  not,  then,  surprising  that  in  a  changeable  cli- 
mate the  child  shotdd  be  subject  to  frequent  chills,  and  that  diarrhoea  should 
be  so  common  a  complaint.  In  England,  the  derangement  is  especially 
prevalent  at  the  end  of  spring  and  the  beginning  of  autumn — seasons  when 
the  warmth  of  the  day  is  rapidly  succeeded  by  the  cool  of  the  evening. 
Moreover,  it  must  be  within  the  experience  of  most  medical  practitioners, 
that  the  sudden  alternations  which  sometimes  occur,  even  in  the  height 
of  summer,  from  excessive  heat  to  a  cool,  or  even  chilly  temperature,  are 
generally  followed  by  an  outbreak  of  diarrhoea  amongst  the  younger 
members  of  the  community.  Rickety  children,  probably  on  account 
of  their  profuse  and  ready  perspirations,  are  especially  liable  to  these 
attacks. 

Whilst  cutting  teeth,  young  children  are  more  than  usually  prone  to 
looseness  of  the  bowels.  In  such  cases,  the  relaxation  is  popularly  ascribed 
directly  to  the  process  of  dentition,  and  the  child  is  said  to  "  cut  his  teeth 
with  diarrhoea. "  There  is,  however,  no  doubt  that  the  teething  process  is 
concerned  in  the  derangement  only  indirectly.  During  dentition,  a  child 
is  often  feverish,  and  pyrexia  from  any  cause  reduces  the  resisting  power  of 
the  body,  and  renders  it  sensitive  in  an  unusual  degree  to  changes  of  tem- 
perature. In  one  case,  the  catarrh  fastens  upon  the  bowels,  in  another  upon 
the  stomach,  in  a  third  upon  the  lungs,  according  to  the  varying  suscepti- 
bility of  the  organs  ;  and  strictly  speaking,  the  child  sufiers  not  because  he 
is  teething,  but  because  he  is  feverish. 

Although  looseness  of  the  bowels  from  the  above-mentioned  causes  is 
usually  transient  and  trifling,  it  is  liable  at  any  time  to  become  severe  and 
even  dangerous.  An  intestinal  catarrh,  unless  quickly  arrested,  is  apt  to 
extend  and  grow  violent,  especially  in  weakly  subjects ;  and  an  attack  of 
diarrhoea  which  begins  mildly  enough,  may  suddenly  change  its  character 
and  assume  very  serious  proportions. 

Morhid  Anatomy. — As  the  derangement  is  not  in  itself  of  much  mo- 
ment, few  opportunities  of  an  examination  of  the  intestine  are  afforded. 
Such,  however,  occasionally  occur  when  the  derangement  has  been  present 
in  a  young  child  who  is  feeble  and  ailing  from  some  more  serious  affection. 
In  such  cases,  the  mucous  membrane  may  appear  to  be  quite  healthy,  and 
if  here  and  there  a  certain  amount  of  arborescent  redness  is  discovered, 
this  is  in  all  probability  a  post-mortem  change.  Occasionally,  an  excess  of 
slimy  mucus  may  be  found  coating  the  lining  membrane  over  a  greater  or 
less  extent  of  surface. 

Symptoms. — In  infants,  the  mild  intestinal  catarrh  which  constitutes  the 
non-inflammatory  form  of  diarrhoea  usually  occurs  suddenly.  Sometimes 
it  is  preceded  for  some  hours  by  slight  griping  pains,  nausea,  or  even  vom- 
iting, a  furred  tongue,  restlessness,  peevishness,  and  other  signs  of  discom- 
fo]-t ;  and  occasionally,  if  a  very  indigestible  substance  has  been  swallowed, 
40 


626  DISEASE  IN   CHILDREN. 

by  some  fever.  In  a  short  time,  a  profuse  discharge  of  thin  feculent  matter 
takes  place  from  the  bowel,  and  the  pyrexia,  if  it  had  been  present,  sub- 
sides at  once.  At  first,  the  evacuations  are  feecal,  and  contain  lumps  of  un- 
digested food.  They  have  often  an  offensive  sour  smell,  and  may  be  frothy 
from  evident  fermentation.  Usually,  the  early  faecal  stools  are  succeeded 
by  thinner,  smaller^watery  or  slimy  dejections,  showing  an  excess  of  mucus, 
and  tinted  of  a  green  colour.  If  the  catarrh  affect  exclusively  the  lower  part 
of  the  larger  bowel,  there  is  much  mucus  and  perhaps  streaks  of  blood  from 
straining.  In  the  first  few  hours  the  stools  are  usually  frequent,  but  after- 
wards they  become  rarer,  and  five  or  six^seldom  more — are  passed  in  the 
course  of  the  twenty-four  hours.  They  are  more  numerous  in  the  day  than 
in  the  night,  and  are  excited  by  liquid  food,  especially  if  this  be  taken  warm 
and  in  large  quantities  at  a  time.  The  belly  is  not  swollen  or  tender,  and  the 
motions  after  the  first  are  usually  voided  without  pain.  If  frequent,  they 
have  a  noticeable  effect  upon  the  nutrition  of  the  child.  He  looks  pale,  and 
his  flesh  quickly  becomes  soft  and  flabby  to  the  touch,  although  to  the  eye 
the  body  may  not  appear  to  be  wasted.  A  thermometer  placed  in  the  rec- 
tum shows  no  increase  of  temperature.  The  duration  of  the  derangement 
varies  from  twenty-four  hours  to  two  or  even  three  days.  If  it  exceed  this 
period,  it  often  jDasses  into  the  more  serious  variety  described  in  the  next 
chapter. 

If  the  diarrhoea  be  due  to  a  chill,  other  signs  of  catarrh  may  usually  be 
detected.  The  child  snuffles  from  slight  coryza,  or  coughs  from  a  trifling 
cold  on  the  chest. 

After  the  age  of  infancy,  the  symptoms  present  little  variety  from  those 
just  described.  The  child  may  complain  of  discomfort  in  the  belly,  but 
preserves  his  spirits,  often  his  appetite,  and  will  not  allow  that  he  is  ill. 
He  is  usually  thirsty,  and  his  tongue  is  furred,  but  his  general  health,  and 
even  his  nutrition,  seem  to  suffer  little,  if  at  all,  from  the  looseness  of  his 
bowels. 

In  children  of  five  or  six  years  of  age  and  upwards  a  form  of  looseness 
of  the  bowels  called  "lienteric  diarrhoea"  is  common.  This  derangement 
consists  in  an  exaggeration  of  the  normal  peristaltic  movement,  which  ap- 
pears to  be  at  once  excited  by  the  taking  of  food.  In  these  cases,  the 
latter  part  of  a  meal  is  accompanied  by  an  uneasy  sensation  in  the  belly 
which  soon  becomes  a  grij)ing  pain,  and  is  quickly  followed  by  an  urgent 
desire  to  evacuate  the  bowels.  Often  the  child  has  to  hurry  away  from  the 
table,  and  the  motions  are  found  to  consist  almost  entirely  of  undigested 
food  and  mucus.  The  bowels  act  in  this  manner  after  each  meal,  and  often 
also  in  the  morning  before  breakfast.  The  abdominal  pain  may  be  com- 
plained of  at  other  times  without  being  followed  by  a  stool.  The  tongue 
is  slightly  furred,  or  is  clean,  red,  and  irritable-looking.  If  this  looseness 
continue  for  several  weeks,  as  it  often  does,  it  causes  considerable  impair- 
ment of  nutrition. 

Treatment. — If  an  infant  be  taken  with  diarrhoea,  the  treatment  will 
vary  according  to  the  period  at  which  the  child  comes  under  observation. 
If  he  is  seen  early,  and  there  ai-e  signs  of  abdominal  discomfort,  especially 
if  the  motions  contain  lumps  of  undigested  curd  and  starch,  it  is  always 
best  to  assist  the  discharge  of  the  offending  matters  by  a  teaspoonful  of  cas- 
tor-oil, or  a  small  dose  of  rhubarb  and  soda  (gr.  iv.-vj.  of  each  with  gr.  j.  of 
powdered  cinnamon).  This  the  child  will  take  readil}^  if  it  be  made  into  a 
paste  with  a  few  drops  of  glj^cerine.  Afterwards  an  antacid  can  be  ordered 
Avith  a  carminative.  The  following,  slightly  altered  and  modernised  from 
an  old  prescription  by  Boerhaave,  is  very  useful : 


DIAEEHCEA — TREATMENT.  627 

^ .  Sapon.  duri  Hispanioli gr.  xvj. 

Cret^e  prsep gr.  xx. 

Syrupi  flor.  aurantii 3  ij. 

Aq.  menthse  sativse 3  iij. 

Aq.  foenicvili ad.    §  j. 

M. 
Sig.  A  teaspoonful  to  be  given  every  eight  hours  to  a  child  between  six 
and  twelve  months  of  age.     To  older  children  it  can  be  given  every  six 
hours. 

If,  after  the  action  of  the  laxative,  the  stools  still  continue  to  contain 
lumps  of  undigested  food,  or  if  the  belly  remain  hard  and  distended,  it  is 
well  to  repeat  the  aperient  until  the  dejections  assume  a  more  healthy 
character. 

Even  if  the  diarrhoea  appears  to  be  occasioned  by  a  chill,  it  should  be 
treated  in  the  same  way  ;  for  there  are  in  such  cases  acrid  secretions  which 
cause  great  iiTitation  of  the  bowels  until  they  are  removed.  At  the  same 
time,  care  should  be  taken  that  the  abdomen  is  kept  warm  with  a  flannel 
binder,  and  that  the  child,  if  nursed,  is  restricted  to  the  breast.  If  he  be 
fed  by  hand,  the  milk  should  be  diluted  with  barley-water,  or  with  water 
in  which  a  little  gelatine  has  been  dissolved,  to  insure  fine  division  of  the 
curd,  and  should  be  allialinised  by  the  addition  of  ten  or  fifteen  drops  of 
the  saccharated  solution  of  lime. 

In  the  large  majority  of  cases,  an  attack  of  simple  diarrhoea  is  quickly 
arrested  by  this  means,  especially  if  care  be  taken  that  the  child  is  confined 
to  the  house  and  guarded  from  further  chill.  If,  however,  the  looseness 
continue,  a  powder  composed  of  rhubarb  (gr.  iij.)  and  aromatic  chalk 
(gr.  V.)  should  be  given  at  night-time  ;  and  in  the  day,  a  small  quantity  of 
laudanum  should  be  prescribed  with  an  antacid  and  warming  aromatic  : 

]J .  Sp.  ammon.  aromat TTl,  xx. 

Tinct.  rhei Til,  xxiv. 

Tinct.  opii guttse  iv. 

Sp.  chlorof ormi Til,  xxiv. 

Aquam  carui ad.  5  j. 

M. 
Sig.  One  teaspoonful  to  be  given  every  eight  hours  to  a  child  of   six 
months  old. 

Oxide  of  zinc  (gr.  j.) ;  bismuth  and  chalk  (gr.  iij.-v.  of  each)  ;  and  the 
old-fashioned  but  not  the  less  useful  chalk  and  catechu  mixture,  are  aU  of 
service,  especially  if  the  stools  are  acid  and  frothy.  So  long,  indeed,  as 
signs  of  fermentation  are  visible,  chalk  with  an  aromatic  should  form  part  of 
the  mixture,  whatever  be  the  combination  adopted.  If  afterwards  the  evac- 
uations become  thin  and  watery,  an  astringent  is  indicated.  Such  cases, 
however,  ought  strictly  to  come  under  the  head  of  inflammatory  diarrhoea, 
and  full  directions  for  their  treatment  will  be  given  in  the  next  chapter. 

If  the  diarrhoea  occur  in  the  course  of  teething,  there  is  often  hesitation 
as  to  the  course  to  be  adopted.  Some  authorities  have  been  of  opinion 
that  the  purging  should  not  in  such  a  case  be  hastily  arrested,  lest  the  fever 
and  local  inflammation  be  thereby  aggravated.  There  is,  however,  no  founda- 
tion for  such  apprehensions.  I  have  never  seen  ill  effects  foUow  from  the 
suppression  of  the  intestinal  flow.  On  the  contrary,  if  the  infant  be  weakly 
and  the  bowels  habitually  irritable,  the  continuance  of  the  relaxation  may 
cause  such  depression  of  the  strength  as  to  place  the  child's  life  in  immi- 


628  DISEASE   Iisr   CHILDEEN. 

nent  danger.  The  wisest  coui-se  to  f ollo-w  is,  first  to  remove  irritating  secre^ 
tions  by  a  mild  aperient,  such  as  the  rhubarb  and  soda  powder,  or  castor- 
oil,  and  afterwards  to  prescribe  one  of  the  antacid  mixtures  given  above. 
Boerhaave's  aromatic  soap  draught  is  very  useful  in  these  cases. 

After  the  age  of  infancy  children  must  be  treated  for  the  mild  form  of 
diarrhoea  upon  precisely  similar  piincij)les  to  those  laid  down  above.  They 
should  be  confined  to  the  house,  and  restricted  in  acid-making  articles  of 
food,  such  as  fruit  and  sweets.  A  dose  of  rhubarb  and  magnesia,  followed 
by  a  di-aught,  several  times  in  the  day,  containing  spirits  of  sal  volatile  with 
chloric  ether  and  a  few  droj)S  of  laudanum,  or  chlorodyne  in  some  aromatic 
water,  will  soon  restore  the  alimentary  mucous  membrane  to  a  healthy 
condition. 

Lienteric  diarrhoea  must  not  be  treated  with  astringents.  The  loose- 
ness is  quickly  an-ested  by  small  doses  of  arsenic  and  nux  vomica.  For  a 
child  of  six  years  old  one  drop  of  Fowler's  solution  of  arsenic  may  be  given, 
with  two  drops  of  tinctui-e  of  nux  vomica,  three  times  a  day,  before  food. 
One  or  two  drops  of  laudanum  may  be  added  if  the  looseness  does  not 
quickly  yield. 


CHAPTEE  Y. 

INFLAMMATORY   DIAREHGEA. 

Inflammatory  diarrhoea  (severe  intestinal  catarrh,  or  entero-coHtis)  is  a  much 
more  serious  disorder  than  the  preceding.  The  purging  may  be  severe 
from  the  first,  or  may  begin  as  a  mild  looseness  of  the  bowels,  which  quickly 
becomes  more  violent,  and  is  accompanied  by  very  evident  impairment  of 
the  strength  and  interference  with  the  general  nutrition  of  the  patient.  In 
feeble  children  and  infants  it  is  often  rapidly  fatal,  and  even  robust  sub- 
jects may  die  coUapsed  after  a  few  days.  In  some  cases  it  passes  into  a 
chronic  stage,  and  if  not  fatal  to  hfe,  may  reduce  the  child  to  a  state  of  ex- 
treme emaciation  and  weakness. 

Causation. — The  causes  which  have  been  enumerated  as  giving  rise  to 
the  simple  non-inflammatory  form  of  diarrhoea  may  also  induce  the  more 
serious  variety  of  intestinal  catarrh.  The  severity  of  the  process  excited  by 
these  agencies  is  probably  often  dependent  upon  constitutional  tendency, 
or  upon  some  special  state  of  the  system  prevailing  in  the  child  at  the  time 
of  the  attack. 

Chilling  of  the  surface  and  improper  feeding  are,  no  doubt,  answerable 
for  many  of  these  cases.  Besides  these,  the  drinking  of  contaminated 
water,  or  the  effluvium  from  decaying  organic  matter  given  out  by  the 
putrefying  refuse  of  large  cities  is,  no  doubt,  a  frequent  cause  of  the  preva- 
lence of  severe  and  often  fatal  diarrhoea  during  the  summer  months.  Not 
unfrequently  several  of  these  causes  are  found  in  operation  at  the  same 
time.  If  an  infant  born  of  poor  parents,  and  living  in  a  badly  dramed  and 
crowded  house,  be  fed  in  hot  weather  from  an  ill-cleaned  and  sour-smelhng 
bottle,  it  may  be  considered  certain  that  acute  inflammatory  diarrhoea  of  a 
violent  character  wiU  very  shortly  follow.  In  bottle-fed  infants,  indeed,  the 
disease  is  especially  common,  and  is  answerable  for  a  large  part  of  the 
mortality  which  occurs  in  cities  during  the  first  twelve  months  of  life. 

Severe  inflammatory  diarrhoea  appears  to  be  almost  confined  to  large 
towns  ;  and  the  mortality  from  this  cause  is  greatest  during  the  months  of 
July,  August,  and  September.  According  to  Dr.  G.  B.  Longstaff,  it  is  not 
so  much  heat  alone,  as  heat  combined  with  drought  that  gives  its  virulence 
to  the  disease  ;  for  the  mortality  is  greatest  in  years  with  hot,  dry  summers, 
least  in  years  when  the  summers  are  cold  and  wet.  This  observer  regards 
the  complaint  as  a  communicable  zymotic  aftection,  and  attributes  its  ori- 
gin to  a  locally  bred  miasma  from  the  soil  or  sewei"-air.  It  seems,  indeed, 
likely  that  in  many  of  the  more  serious  cases  of  acute  inflammatory  diar- 
rhoea there  may  be  a  strong  septic  element  in  the  illness.  Certainly  we 
often  find  a  degree  of  nervous  prostration  quite  out  of  proportion  to  the 
amount  of  purging.  Indeed,  a  state  of  exhaustion  may  continue  after  the 
diarrhoea  has  been  arrested,  and  end  in  death,  although  days  have  passed 
without  any  excessive  looseness  of  the  bowels  having  been  noticed. 

Weakness  of  the  child,  as  might  be  expected,  favours  the  occuri'ence  of 


630  DISEASE  IN   CHILDEEN. 

inflammatory  diarrlioea  ;  but  there  are  cei-tain  diseases  which  are  commonly 
accompanied  by  catarrh  of  the  bowel.  Thus  in  typhoid  feyer  diarrhoea  is 
a  frequent  symptom  ;  and  in  measles  and  scarlatina  piu-ging  may  form  a 
very  serious  comphcation.  Again,  causes  which  joromote  congestion  of  the 
portal  system,  such  as  cirrhosis  of  the  hyer,  and  diseases  of  the  heart  and 
lungs,  which  impede  the  passage  of  the  blood  from  the  right  side  of  the 
heart  to  the  left,  and  therefore  interfere  with  the  whole  venous  cii'culation, 
may  also  help  to  detennine  the  derangement. 

Morbid  Anatomy. — The  catarrh  of  the  intestine  is  seldom  general,  usu- 
ally it  is  ver}^  partial,  and  is  limited  to  the  large  intestine  and  jejunum. 
On  oj)ening  the  bowel  we  find  the  hning  membrane  coated  at  the  inflamed 
part  with  a  layer  of  thick  mucus  containing  detached  epithelial  scales.  The 
mucous  membrane  itself  is  reddened,  and  often  thickened,  and  its  sohtary 
glands  and  the  glands  of  Peyer's  patches  are  swollen  so  as  to  project  above 
the  surface.     Sometimes  the  mesenteric  glands  are  a  httle  swollen. 

If  the  inflammation  have  passed  into  a  chronic  stage  it  is  dark  gray  or 
dii'ty  red  in  colour-,  and  the  enlarged  follicles  can  be  seen  as  small,  pearly  pro- 
jections. In  some  cases  patches  of  false  membrane  are  seen  on  the  sui-face, 
especially  in  the  large  intestine.  The  mucous  membrane  then  has  the  ap- 
pearance of  being  sjDrinkled  over  with  bran.  The  httle  patches  consist  of 
exuded  lymph  containing  epithelial  scales.  They  vary  in  size  and  shape,  and 
usually  occupy  the  summits  of  the  ridges  of  the  mucous  membrane. 

If  the  catarrhal  j^rocess  has  lasted  long  or  been  very  serious  we  often, 
find  ulcerations.  These  are  usually  seen  in  the  large  intestine,  especially 
towards  the  lower  part,  and  in  the  lower  part  of  the  ihum.  The  ulcers  are 
seated  at  the  follicles  and  result  from  suppuration  and  ulceration  starting 
from  the  interior.  They  are  at  first  circular  but  may  extend  their  edges  ir- 
regularly. Not  rarely  we  find  intussusceptions  of  the  bowel.  These  usuaUy 
occupy  the  small  intestine,  and  several  may  be  present  at  the  same  time. 
They  are  e^^dently  produced  immediately  before  death,  for  the  invaginated 
portions  can  be  readily  draAvn  out  and  show  no  sign  of  congestion  or  swell- 
ing. 

In  many  cases  of  severe  intestinal  catan'h  the  hver  is  fatty.  Another 
frequent  complication,  according  to  Kjellberg,  is  parenchymatous  nejDhi'itis. 
This  physician  states  that  in  143  cases  of  fatal  intestinal  catarrh  he  found 
kidney  disease  in  no  less  than  67.  It  is  more  common  in  infants  than  in 
older  children,  and  is  often  partial,  attacking  only  a  portion  of  the  cortical, 
substance. 

Syraptoms. — The  symptoms  of  acute  inflammatory  dian-hoea  vary  to 
some  extent  according  to  the  age  of  the  child.  As  a  rule,  if  the  purging 
be  profuse  the  drain  upon  the  system  causes  symptoms  of  depression,  which 
come  on  earher  and  are  more  severe  in  infancy  than  a!:  a  later  period  of 
childhood.  Moreover,  in  infancy  the  intestinal  disorder  is  apt  to  be  accom- 
panied by  symptoms  dependent  upon  parenchymatous  nephi-itis  ;  and  this 
complication  is  not  so  often  seen  after  the  period  of  the  first  dentition  has 
come  to  an  end.  The  derangement  will,  therefore,  be  first  described  as  it 
affects  infants,  and  afterwards  as  it  is  met  with  in  older  childi'en. 

In  infants  infiammatory  diarrhoea  usually  begins  like  the  milder  form, 
with  symptoms  of  discomfort  about  the  beUy  and  some  looseness  of  the 
bowels  ;  but  the  purging  soon  becomes  more  severe.  If  there  be  any  gas- 
tric catarrh,  the  child  often  vomits  ;  and  both  the  matter  ejected  from  the 
stomach  and  that  discharged  from  the  bowels  is  acid  and  sour-smeUing, 
The  stools  at  first  contain  much  curd  and  undigested  food,  but  rapidly  change 
their  character  and  become  thin  and  watery.    They  are  brownish  or  greenish 


IlSrFLAMMATOEY   DIAREH(EA — SYMPTOMS.  631 

in  colour,  and  give  out  a  most  offensive  odour.  Unless  tlie  lower  bowel  be 
affected  there  is  little  mucus  visible  to  the  eye,  and  the  stools  are  passed 
without  strainmg"  or  signs  of  pain  in  the  belly.  In  number  they  vary  from 
six  or  seven  to  fifteen  or  twenty,  or  even  more,  in  the  twenty-four  hours. 
Their  character  is  found  to  change  from  time  to  time,  partly  according  to 
the  frequency  of  their  passage.  Thus,  if  they  follow  rapidly  upon  one  an- 
other they  usually  consist  of  dark-coloured  watery  fluid,  which  deposits  thick 
feculent  matter  on  standing.  If  separated  by  a  longer  interval,  they  become 
thicker  and  more  distinctly  faecal,  and  may  contain  small  lumps  of  curd. 
Often  they  vary  in  character,  and  are  at  different  times  light  and  pasty,  or 
frothy  and  dark,  or  green  and  very  liquid.  They  are  almost  always  very 
offensive.  Under  the  microscope  Dr.  Lewis  Smith  has  detected  undigested 
particles  of  casein,  fibres  of  meat,  crystalline  formations,  epithelial  cells — 
single  or  arranged  in  clusters — mucus,  and  sometimes  blood.  According  to 
Nothnagel,  of  Jena,  mucus,  invisible  to  the  naked  eye,  but  perceptible  under 
the  microscope,  indicates  a  catan'h  of  the  smaller  bowel. 

The  general  symptoms  are  very  severe.  The  infant  rapidly  wastes,  and 
becomes  so  weak  that  he  cannot  sit  up.  His  eyes  get  hollow;  his  face  is 
very  pale  ;  the  nasal  line  encircling  the  corners  of  his  mouth  becomes 
deepened  into  a  distinct  wrinkle,  and  erythematous  redness  appears  upon 
the  buttocks  and  inner  parts  of  the  thighs  from  the  irritation  of  the  dis- 
charges ;  the  skin  is  dry,  and  the  amount  of  urine  is  gTeatly  diminished. 
Often  the  tongue  is  quite  clean  and  red,  although  less  moist  than  in  health, 
and  there  is  great  thirst.  If  there  is  much  gastric  catarrh,  the  tongue  may 
be  fun-ed  upon  the  dorsum,  and  vomiting  is  often  a  distressmg  symptom. 
The  pulse  is  rapid  and  feeble.  The  temperature  varies.  Sometimes  it  re- 
mains unaltered  or  may  even  be  subnormal ;  in  other  cases  it  reaches  to 
102°  or  103°,  rising  and  falling  irregularly,  but  never  dropping  to  the  level 
of  health. 

After  a  few  days,  the  earlier  in  proportion  to  the  profuseness  of  the 
drain,  the  child  falls  into  a  state  of  profound  depression,  with  quick,  feeble 
pulse,  and  rapid,  shallow  breathing.  The  eyes  are  hollow,  the  purple  lids 
close  incompletely,  and  the  face,  especially  round  the  mouth,  is  livid.  The 
fontanelle  is  deeply  depressed.  The  tongue  often  gets  dry  and  brown,  and 
thrush  may  appear  upon  the  cheeks  and  lips.  Often,  although  the  hands  and 
feet  feel  cold,  the  internal  temperature  of  the  body  is  very  high.  A  ther- 
mometer placed  in  the  rectum  will  sometimes  mark  107°,  or  even  higher, 
although  the  child  s  general  apj)earance  is  that  of  collapse.  Thus,  a  Uttle 
boy,  aged  nine  months,  had  suffered  from  diarrhoea  for  a  week,  and  was 
occasionally,  sick.  When  seen  the  motions  were  light  coloured,  watery, 
and  offensive.  His  temperature  (in  the  rectum)  was  105.6° ;  pulse,  176  ; 
respirations,  64.  On  the  following  morning  the  tempera tm-e  was  103°  ;  but 
in  the  evening  it  rose  to  107.8°,  and  the  child  died  a  few  hours  afterwards. 
Just  before  death  the  thermometer  marked  106°.  Another  infant,  ten  months 
old,  had  diarrhoea  for  about  a  fortnight,  the  bowels  acting  five,  six,  or  seven 
times  in  the  day.  At  this  time  the  temperature  was  normal.  It  then  be- 
gan to  rise,  and  for  a  few  days  varied  between  101°  and  102°.  Then  it  rose 
rapidly  to  107.4°,  and  the  child  died  with  aU  the  signs  of  collapse.  In 
neither  of  these  cases  was  permission  obtained  to  make  examination  of  the 
body,  but  no  complication  could  be  discovered  during  life  to  account  for 
the  elevation  of  temperature. 

When  the  catarrh  is  seated  in  the  larger  bowel,  especially  if  it  affects 
principally  the  descending  colon  and  rectum,  the  symptoms  are  more  dys- 
enteric in  character.     Indeed,  this  form  of  inflammatory  diarrhoea  is  often 


632  DISEA.SE  IN   CHILDEEN. 

improper^  spoken  of  as  "  dysentery."  The  infant  usually  cries  before  the 
passage  of  a  stool  from  griping  pains  in  the  belly ;  and  the  evacuations  are 
discharged  with  great  effort  and  straining.  Often  the  bowel  prolapses,  and 
the  motions  contain  streaks  or  drops  of  red  blood.  The  stools  themselves 
consist  of  shmy  matter  from  admixture  with  mucus,  and  lumps  of  coagu- 
lated mucus  can  be  distinctly  perceived  in  the  fsecal  matter.  Sometimes 
the  straining  continues  for  a  considerable  time  after  the  passage  of  the 
motion,  and  the  prolapsed  bowel  protrudes  like  a  bright  crimson  ball  fi-om 
the  anus.  Often  it  can  be  returned  only  with  great  difficulty,  and  when 
replaced  is  shot  out  again  directly  by  the  straining.  In  this  form  the  stools 
may  be  as  numerous  as  when  the  small  intestine  is  affected,  the  vomiting 
as  distressing,  and  the  prostrating  effect  upon  the  system  of  the  constant 
purging  quite  as  pronounced.  Indeed,  if  the  tenesmus  is  urgent  and  the 
protrusion  of  the  inflamed  bowel  almost  constant,  the  case  is  very  likely  to 
end  fatally. 

If  the  derangement  be  complicated  with  parenchymatous  nephritis,  the 
signs  of  general  collapse,  into  which  the  infant  in  fatal  cases  almost  invaria- 
bly sinks,  are  diversified  by  others  pointing  to  the  kidne3^  According  to 
Kjellberg's  descrij^tion  of  such  cases  the  tongue  is  dry,  the  skin  upon 
the  abdomen  is  cool  and  dry,  and  its  elasticity  is  completely  lost,  so  that 
when  pinched  up  it  remains  wrinkled,  lying  in  loose  folds  ;  the  legs  are 
stretched  out  and  stiff,  often  oedematous ;  the  urine  is  very  scanty,  albu- 
minous, and  deposits  a  sediment  containing  epithehal  and  hyaline  casts  and 
small  round  cells.  The  child  vomits  occasionally,  sometimes  shrieks  out, 
and  may  be  convulsed.  In  the  very  acute  cases  the  infant  is  restless,  with 
a  very  rapid  pulse  and  hot  skin.  He  flexes  his  thighs  on  his  beUy,  and  al- 
though drowsy  and  stui3id,  screams  at  times  with  pain,  and  appears  to  feel 
acutely  the  slightest  touch  upon  his  body. 

In  the  more  protracted  cases  the  infant  often  falls  into  a  comatose 
state,  which  from  its  resemblance  to  the  third  stage  of  meningitis  has  been 
called  "  spurious  hydrocephalus."  The  child  lies  in  a  drowsy  condition, 
from  which,  however,  he  can  at  first  be  roused.  His  eyehds  are  half 
closed ;  the  pupils  are  sluggish  and  may  be  unequal ;  the  pulse  is  rapid, 
•  and  often  intermittent ;  the  breathing  is  irregular  and  sometimes  sighing  ; 
the  fontanelle  is  deeply  depressed  ;  the  features  are  pinched  and  sharp ; 
and  the  complexion  is  livid  or  even  lead-coloured.  The  temperatui-e  taken 
in  the  rectum  is  subnormal.  While  in  this  state  the  stools — small,  wa- 
tery, and  often  greenish — may  continue,  and  be  passed  involuntarily ;  or 
the  purging  may  cease,  but  without  being  followed  by  any  signs  of  im- 
provement. Unless  energetic  measures  of  stimulation  are  adopted,  the 
child  continues  in  the  same  state  for  twelve  or  twenty-four  hours,  or  even 
several  days,  growing  weaker  and  weaker,  and  death  may  be  preceded  by 
a  shght  convulsive  seizure. 

Spurious  hydrocephalus  may  be  the  consequence  merely  of  sluggish 
circulation  through  the  brain  of  impoverished  blood.  Often,  however,  it 
appears  to  be  owing  to  the  occurrence  of  thrombosis  in  the  cerebral  sinuses. 
Parrot  has  suggested  that  it  may  be  sometimes  due  to  ursemic  poisoning 
from  deficient  renal  secretion. 

When  the  disease  occurs  after  the  age  of  infancy,  the  child  is  usually 
able  to  resist  the  exhausting  effects  of  the  diarrhoea  for  a  longer  period 
than  is  possible  at  the  earlier  age  ;  but  he  rapidly  loses  flesh  and  strength, 
and  if  the  pm-ging  is  severe  and  is  accompanied  by  vomiting,  the  features 
soon  look  pinched,  the  eyes  get  hollow,  and  the  expression  is  haggard  and 
distressed.     Unless  the  lower  bowel  is  affected,  pain  in  the  beUy  is  usually 


INFLAMMATORY   DIAEEHOEA — CHRONIC    FORM.  633 

insignificant  ;  but  if  the  descending  colon  is  the  seat  of  the  derangement, 
thei'e  is  much  tenesmus  and  griping  pain,  and  the  bowel  may  prolapse. 
The  temperature  in  these  cases  is  usually  moderately  elevated  during  the 
earlier  period  of  the  attack,  but  often  falls  to  a  lower  level  than  that  of 
health  when  the  purging  has  produced  much  depression  of  strength. 

The  stools  are  very  watery  and  offensive,  usually  dark  in  colour,  and  if 
much  milk  is  being  taken,  may  contain  lumps  of  curd.  Sometimes,  espe- 
cially in  very  hot  weather,  they  may  be  yellow  or  green  from  excessive 
secretion  of  bile.  The  urine  is  comparatively  scanty  and  high-coloured. 
According  to  Nothnagel,  if  the  small  intestine  is  the  seat  of  catarrh,  the  ex- 
cretion of  indican  is  in  excess.  When  death  takes  place  it  is  usually  by 
asthenia  ;  but  spurious  hydrocephalus  is  uncommon  after  the  period  of  in- 
fancy has  passed,  and,  according  to  Kjellberg,  kidney  complication  after 
that  age  is  equally  rare. 

At  all  ages  the  symptoms  of  prostration  come  on  earlier  and  are  more 
pronounced  if  the  child  is  already  reduced  in  strength  when  the  attack 
begins,  and  therefore  inflammatory  diarrhoea  occurring  as  a  secondary 
complication  in  a  child  worn  and  wasted  by  previous  illness  is  an  exces- 
sively serious  derangement. 

The  chronic  form  of  intestinal  catarrh  is  a  very  obstinate  and  dangerous 
disorder,  and  unless  treated  judiciously  is  almost  certain  to  end  fatally. 
It  may  succeed  directly  to  an  acute  attack,  or  may  begin  insidiously.  If  it 
occur  as  a  sequel  of  the  acute  variety,  the  stools  gradually  become  fewer 
and  the  more  urgent  symptoms  subside.  The  child,  however,  does  not  re- 
gain flesh  or  strength,  but  remains  feeble  and  paUid.  His  bowels  act  three 
or  four  times  a  day,  and  the  evacuations  consist  of  thin,  dark,  offensive 
fluid,  or  of  equally  offensive  pasty  matter  and  mucus. 

The  insidious  beginning  of  the  chronic  disorder  is  very  common.  If 
detected  early  and  treated  with  judgment,  it  is  readily  arrested  ;  but  if  it 
continue  unchecked,  it  becomes  a  confirmed  derangement  and  is  much 
more  difl&cult  of  cure.  Still,  even  in  bad  cases  the  disorder  may  be  usually 
guided  to  a  successful  issue  if  proper  measures  are  adopted. 

A  child  of  eighteen  months  or  two  years  of  age  is  noticed  to  be  looking 
pale,  and  his  flesh  is  found  to  be  flabby.  Then  he  shows  less  than  his 
usual  pleasure  at  being  on  his  legs,  and  if  the  power  of  walking  have  been 
only  lately  acquired,  often  refuses  altogether  to  put  his  feet  to  the  ground. 
These  symptoms  occasion  great  perplexity  to  the  attendants,  for  the  child's 
appetite  continues  good — -often  unusually  keen — and  his  bowels  are  regu- 
larly relieved.  On  inquiry  it  will  be  found  that  the  motions  are  more  nu- 
merous than  natural,  often  three  or  four  in  the  day ;  that  they  are  large, 
offensive,  and  sour-smeUing,'and  that  in  appearance  they  resemble  a  mass 
of  soft  putty.  If  only  one  or  two  stools  occur  in  the  day,  they  are  often 
curiously  copious ;  and  the  mother  will  declare  that  the  quantity  of  food 
consumed  by  the  child,  considerable  as  it  may  be,  is  quite  insufficient  to 
account  for  the  enormous  amount  of  matter  passed  from  the  bowels. 

For  weeks,  perhaps,  these  symptoms  go  on  unchanged.  The  wasting 
continues,  and  all  power  of  digesting  what  is  swallowed  seems  to  be  lost. 
Occasionally  for  two  or  three  days  together  the  bowels  are  relaxed,  the 
stools  being  frothy  and  sour-smelHng,  or  thin  and  dark-coloured  like  dirty 
water ;  but  the  diarrhoea  soon  ceases  and  the  motions  again  become  large, 
soft,  and  pasty,  as  they  were  before.  The  attacks  of  acute  catarrh  repeat- 
edly return,  the  intervals  between  them  grow  shorter,  and  eventually  the 
looseness  becomes  a  confirmed  condition.  Often,  however,  a  considerable 
time  may  elapse  before  this  stage  is  arrived  at.     The  child  for  months  may 


634  DISEASE   IX   CHILDREN". 

remain  pale  and  listless,  -witli  ciuious  alternations  of  voracity  in  feeding 
and  disgust  for  noin-islnnent  of  every  kind.  He  is  not  feverish  but  s^Yeats 
copiously.  There  is  no  actual  diarrhoea,  perhaps  even  no  increased  fre- 
quency of  stool.  Xo  pain  is  complained  of.  The  mother  will  say  that  she 
cannot  think  "^hat  is  the  matter  with  the  child,  but  that  he  is  wasting  away. 

When  the  diarrhoea  becomes  persistent,  the  stools  vary  in  character  fi'om 
time  to  time.  In  any  case,  they  have  an  intolerable  stench  ;  and  may  be 
dai'k  coloured  and  watery  ;  or  thicker,  but  still  fluid,  hke  thin  paste  ;  or 
may  consist  of  green  matter,  like  chopped  spinach,  diffused  thi'ough  a  dai'k 
brown  hquid.  If  they  show  a  shi'eddy  deposit,  mixed  with  small  black  clots 
of  blood,  ulceration  of  the  bowels  may  be  confidently  predicated,  even  al- 
though no  tenderness  of  the  abdomen  can  be  detected. 

The  wasting  now  proceeds  rapidly.  The  child  gets  hollow-eyed,  wi'inkled, 
and  old-looking.  His  belly  swells  from  flatulent  distention.  His  hmbs 
often  become  oedematous.  He  is  excessively  feeble,  and  lies  cj^uite  motion- 
less, taking  httle  notice  of  anything.  His  appetite  may  be  good,  even  at  this 
stage,  but  often  it  is  capricious  or  altogether  lost.  The  water  is  diminished 
in  quantity,  if  the  pui-ging  is  severe,  and  may  contain  fi'om  time  to  time,  a 
httle  uiic  acid  sand.  Eventually,  the  child  sinks  into  a  state  of  exliaustion, 
and  dies  fi'om  asthenia,  or  is  carried  oiT  by  an  attack  of  inflammation  of  the 
lung.  All  the  symptoms  which  have  been  described  as  spuiious  hydi'O- 
cephalus,  may  be  noticed  before  death,  and  the  diarrhoea  may  C[uite  cease 
during  the  last  few  days  of  the  illness. 

These  insidious  cases  ai'e  more  common  during  the  second  year  of  life, 
than  at  any  other  period,  although  they  may  also  occui'  later.  When  the 
complaint  arises  as  a  result  of  an  acute  attack,  chi'onic  diarrhoea  is  often 
met  with  dui'ing  the  first  year,  and  is  especially  fi'ecjuent  in  infants  who 
have  been  weaned  early  and  fed  afterwards  on  unsuitable  food. 

Diagnosis. — Lifiammaton"  diarrhoea,  if  accompanied  by  pyrexia,  may  be 
confounded  with  typhoiol  fever.  The  disting-uishing  points  between  these 
two  diseases  are  pointed  out  elsewhere  (see  page  83). 

The  severity  and  danger  of  the  attack  may  be  detected  from  the  fii'st,  by 
noticing  that  the  temperatur'e  in  the  rectum  is  raised.  In  simple  diaiThoea, 
the  temperature  is  normal  after  the  first  stooL  It  is  a  ciuestion  of  con- 
siderable interest  to  ascertain  the  exact  seat  of  the  cataiTh.  The  presence 
of  jaundice  would,  of  coui'se,  inolicate  that  the  duodenum  was  involveol ;  and 
tenesmus,  with  or  without  prolapsus  ani,  would  point  to  the  rectum.  From 
a  series  of  carefiil  and  laborious  investigations,  canied  out  by  Prof.  Noth- 
nagel,  who  submitted  to  microscopical  examination  more  than  one  thousand 
specimens  of  catarrhal  stools,  considerable  addition  has  been  made  to  our 
knowledge  of  the  distribution  of  the  lesion  in  cases  of  intestinal  cataiTh. 
According  to  this  authority,  mucus  is  passed  in  considerable  c^uantity  in 
other  forms  of  catarrh  besides  that  aftecting  the  lower  bowel,  and  can  be 
detected  by  the  microscope  when  not  visible  to  the  naked  eye.  The  amount 
of  mucus,  and  its  more  or  less  intimate  aclmixtui-e  -oith  the  faecal  matter,  fui'- 
nishes  important  evidence  ;  so,  also,  fi'om  the  presence  or  absence  of  bile- 
stained  mucus  and  eiDitheliirm,  much  infoiTnation  can  be  derived.  The  re- 
sults of  Prof.  Xothnagel's  researches  may  be  thus  briefly  summarised  : 

If  the  catarrh  affect  the  jejunum  and  ilium,  no  mucus  can  be  seen  by 
ordinary  inspection  of  the  stools  ;  but  when  a  specimen  is  placed  unoler  the 
microscope  between  two  thin  plates  of  glass,  islets  of  mucus  are  distinctly 
visible.  We  can  then  affii'm  positively  that  the  catarrh  is  seated  in  the 
small  intestine,  and  that  the  colon  is  healthy.  If  the  mucus  is  tinted  with 
bile  pigment,  it  also  indicates  jejunal  and  Uial  cataiTh  ;  but,  in  addition,  it 


INFLAMMATOEY   DIAEEHCEA — DIAGNOSIS — PEOGNOSIS.        635 

shows  that  there  is  increased  peristaltic  action  of  the  colon  and  the  lower 
part  of  the  ilium.  In  tliese  cases,  the  stools  are  always  liquid,  for  if  re- 
tained in  the  colon  sufficiently  long  to  acquire  firmness,  the  bile  pigment 
is  always  transformed,  and  the  play  of  colours  in  Gmehn's  test  can  no 
longer  be  obtained.  Besides  bile-stained  mucus,  cells  of  cyhndrical 
epithelium,  leucocyte-like  corpuscles,  and  fat-globules,  all  tinted  with  bile, 
can  be  observed.  In  addition,  on  examining  the  -urine,  the  indican'  ex- 
cretion is  found  to  be  in  excess. 

When  the  larger  bowel  is  affected,  no  bile-tinted  mucus  globules  can 
be  perceived.  The  stools  are  of  a  pulpy  consistence,  and  the  mucus  they 
contain  is  distinctly  visible  to  the  unassisted  sight.  The  nearer  the  af- 
fected part  of  the  bowel  is  to  the  caecum,  the  more  intimate  is  the  admix- 
ture of  the  mucus  with  the  general  feecal  mass.  If  pure  mucus  is  passed 
in  large  quantity,  we  may  conclude  that  the  sigmoid  flexure  or  the  bowel 
below  it  is  the  part  involved  ;  and  scybala  embedded  in  mucus,  point  dis- 
tinctly to  the  rectum. 

Spurious  hydrocephalus  does  not  present  much  difficulty  in  diagnosis. 
The  history  of  exhausting  disease,  the  depressed  fontanelle,  the  low  tem- 
perature, and  the  signs  of  general  prostration,  sufficiently  mark  out  this 
condition  from  the  ordinary  forms  of  cerebral  disease. 

Prognosis. — Inflammatory  diarrhoea  is  so  fatal  a  complaint  in  weakly 
children  that  it  is  very  important  to  estimate  the  chances  of  a  favoui-able 
ending  to  the  derangement.  Much  will  depend  u]3on  the  age  of  the  child, 
the  sanitary  conditions  under  which  he  is  living,  and  the  state  of  his  pre- 
vious health.  The  disease  is  most  dangerous  in  babies  who  have  been 
weaned  early,  and  fed  afterwards  on  excess  of  farinaceous  food,  or  with  por- 
tions of  their  parents'  meals.  Such  infants  are  weakly  and  ill-nourished 
at  the  time  of  the  attack,  with  irritable  bowels  from  their  unsuitable  diet, 
A  severe  acute  catarrh  coming  on  under  such  conditions,  rapidly  reduces 
their  remaining  strength,  and  very  commonly  ends  fatally.  Older  children, 
having  greater  vigour,  are  often  able  to  battle  through  a  complaint  which 
would  kill  a  yotmger  and  weaker  subject.  Therefore,  after  the  age  of  in- 
fancy has  passed,  the  prognosis  is  more  favourable  than  at  an  earlier  pe- 
riod ;  but  even  in  these  cases,  if  the  attack  is  violent  and  the  purging 
severe,  the  danger  is  not  shght,  and  the  derangement  may  resist  all  our 
efforts  to  arrest  its  course. 

At  all  ages,  the  case  is  more  serious  if  the  temperature  is  high  than  if 
it  be  only  moderately  elevated.  Also,  great  frequency  in  the  stools  ;  vio- 
lent vomiting  ;  early  collapse  ;  unusual  drowsiness  or  stupor  ;  stertorous 
breathing  ;  convxdsions,  or  other  sign  of  cerebral  complication,  and  any 
sudden  marked  increase  in  the  pyrexia — all  these  are  signs  of  very  serious 
import.  On  the  contrary,  a  fall  in  the  rectal  temperature  is  of  good 
omen.  If  the  internal  heat  of  the  body  be  found  to  have  become  normal, 
we  may  entertain  hopes  of  improvement,  although  the  general  symptoms 
appear  to  have  undergone  no  change.  ' 

In  the  chronic  form,  the  prognosis  is  also  more  serious  in  children 
under  the  age  of  two  years.  Another  very  important  matter  is  the  per- 
sistence of  the  diarrhoea.  If  the  purging  is  a  confirmed  derangement,  our 
chances  of  success  are  much  fewer  than  if  intervals  occur,  however  short, 

'  To  test  for  indican  : — Add  to  the  tirine  to  be  examined,  an  equal  quantity  of  fu- 
ming hydrocliloric  acid,  and  then  with  a  pipette,  pour  down  a  few  drops  of  strong  solu- 
tion of  chloride  of  lime.  If  no  indican  be  j^resent,  the  colour  of  the  urine  so  treated 
beconaes  red  or  violet  from  the  action  of  the  test  on  some  unknown  constituent.  If 
indican  be  contained  iu  the  urine,  the  colour  of  the  tiuid  becomes  dark  green  or  blue. 


636  DISEASE  IN   CHILDEEIST. 

in  which  the  stools  are  merely  soft  and  pasty  without  being  relaxed.  If 
•ulceration  of  the  bowels  has  occmTed,  we  should  look  forward  to  the  ter- 
mination of  the  illness  with  very  serious  apprehension  (see  Ulceration  of 
the  Bowels). 

Treatment. — In  all  cases  of  severe  diarrhoea  in  the  child,  especially  in 
the  infant,  our  first  care  should  be  to  place  the  patient  at  once  upon  a  suit- 
able diet.  This  subject  is  of  the  first  importance  ;  for  it  is  indispensable 
to  imjjrovement  that  all  food  be  withheld  which  is  capable  of  fermenting 
and  giving  rise  to  acidity.  Our  object  is  to  fui'nish  the  child  with  a  diet 
which  vyill  supply  nourishment  to  the  system  without  leaving  an  undigested 
residue  to  irritate  the  bowels,  and  so  aggravate  the  derangement  we  ai'e 
endeavouring  to  cure.  Milk,  in  particular,  must  be  prohibited  unless  the 
jDatient  be  an  infant  at  the  breast.  If  he  be  suckled,  it  will  sometimes  be. 
found  that  restricting  the  child  entirely  to  his  mother's  breast  is  followed 
by  improvement.  Often,  however,  even  this  diet  will  not  agree,  and  other 
means  will  have  to  be  adopted.  A  hand-fed  baby  must  be  fed  with  whey 
and  cream,  or  whey  and  barley-water  in  equal  proportions,  or  with  weak 
veal  or  chicken  tea  diluted  with  whey  or  barley-water.  The  food  should 
be  given  cold,  and  in  small  quantities  at  a  time.  If  the  child  is  weakly, 
and  in  any  case  if  he  show  signs  of  becoming  exhausted,  white  wine  whey 
is  of  great  service.  This  must  be  given  cold  in  suitable  quantities  at  regu- 
lar intervals.  Thus,  a  feeble  infant  will  take  a  tablespoonful  every  hour 
with  advantage  at  first.  Afterwards,  as  the  need  for  stimiolation  grows  less 
pressing,  other  foods  may  be  alternated  with  the  white  wine  whey  ;  or  this 
may  be  given  only  two  or  thi'ee  times  in  the  day. 

Koumiss  has  been  used  largely  in  these  cases,  and  sometimes  appears  to 
agree.  My  own  experience  of  this  food,  however,  has  not  been  c[uite  satis- 
factory. Li  giving  koumiss  to  a  young  child,  the  gas  should  be  first  ex- 
pelled by  pouring  the  fluid  several  times  from  one  vessel  to  another.  The 
quantity  allowed  to  be  taken  at  each  meal  must  be  proportioned  to  the  se- 
verity of  the  purging.  If  this  be  insignificant,  the  child  may  take  the 
whole  contents  of  his  feeding-bottle.  If,  on  the  contrary,  the  looseness  be 
frequent  and  exhausting,  koumiss,  Hke  other  fluids,  must  be  given  si^aringly, 
and  the  quantity  taken  on  each  occasion  must  be  very  carefully  restricted. 
The  addition  of  MeUin's  food  to  any  of  the  first^named  fluids  is  useful,  and 
in  most  cases  answers  well. 

Older  children  should  be  fed,  while  the  temperature  is  high  and  the 
purging  severe,  vdth  plain  whey,  barley-water,  and  weak  veal  or  chicken 
broths,  given  in  small  quantities ;  or  if  tlae  strength  is  failing,  with  the  wine 
whey,  or  brandy-and-egg  mixt\u-e,  and  strong  meat  essence.  T\Tien  the 
fiLrst  "siolence  of  the  disease  has  abated,  the  patient  may  begin  to  take  milk, 
but  it  should  be  well-diluted  with  barley-water  to  insure  fine  division  of 
the  curd,  and  be  alkalinised  by  the  addition  of  the  saccharated  solution 
of  lime,  fifteen  or  twenty  drops  to  the  teacupful.  Whatever  be  the  age  of 
the*  patient,  any  sign  of  exhaustion  must  be  combated  by  energetic  stimu- 
lation. Brandy  must  be  given  internally,  and  the  skin  must  be  ii-ritated 
by  warm  mustard  baths. 

After  regulation  of  the  diet,  the  next  matter  is  to  see  that  the  belly  is 
kept  warm.  The  whole  abdomen  should  be  covered  with  a  thick  layer  of 
cotton  wadding,  and  this  must  be  kept  in  place  by  a  broad  flannel  binder. 
If  there  is  any  tendency  to  coldness  of  the  feet,  they  must  be  warmed  by  a 
hot  bottle. 

Purity  of  the  air  is  another  point  which  is  not  to  be  neglected.  The 
window  should  be  opened — care  being  of  coui-se  taken  that  the  child  is 


IlSrFLAMMATOEy   DIAEKH(EA — TEEATMEFT.  637 

not  exposed  to  draught — and  a  free  circulation  of  air  through  the  room  can 
be  insured  by  a  small  lamp  placed  in  the  fire-grate.  Few  persons  should 
be  allowed  in  the  sick  room  ;  and  all  soiled  linen  should  be  removed  at 
once  to  another  part  of  the  house. 

In  all  cases  of  severe  intestinal  catarrh,  a  careful  watch  should  be  kept 
over  the  temperature,  and  any  great  increase  in  the  bodily  heat  should  be 
at  once  reduced  by  tepid  bathing.  In  tropical  climates,  the  treatment  of 
inflammatory  diarrhoea  by  baths  has  been  found  very  successful.  A  point 
of  great  practical  importance  in  applying  this  method,  is  to  remember  the 
depressing  effect  of  the  illness,  and  to  be  careful  that  the  application  of  cold 
is  not  carried  to  the  point  of  inducing  prostration.  The  more  weakly  the 
child,  the  more  careful  should  we  be  so  to  regulate  our  measures,  as  to  avoid 
a  shock  to  the  system  which  might  be  too  severe  to  awaken  any  responsive  re- 
action. The  use  of  the  bath  at  once  reduces  the  temperature,  and  even  in 
cases  which  eventually  prove  fatal,  its  immediate  effect  is  often  encouraging. 

A  httle  girl,  aged  twelve  months,  with  twelve  teeth,  was  seized  with  se- 
vere diarrhoea.  The  stools  were  buff-coloured  and  watery,  without  lumjDS, 
and  were  passed  very  frequently  in  the  day.  After  about  a  week,  the  de- 
jections became  frothy,  and  had  a  dark  green  tint.  There  was  much  tenes- 
mus, and  the  bowel  sometimes  prolapsed.  On  an  average,  there  were  about 
fifteen  stools  in  the  twenty-four  hours.  The  child  was  very  weak,  and  had 
no  appetite,  but  was  thirsty.     She  never  vomited. 

When  first  seen  on  the  twelfth  day  of  the  purging,  the  tongue  was  red,  vdth 
some  fur  on  the  dorsum.  The  skin  was  inelastic.  The  abdomen  was  distended, 
but  unless  the  child  strained,  the  parietes  were  flaccid,  and  there  was  no 
tenderness.  The  eyes  were  hollow,  the  mouth  livid,  and  the  nasal  line  was 
well  marked.    The  fontanelle  was  depressed.    The  temperature  was  103.4°. 

The  child  was  ordered  to  be  fed  with  veal-broth  and  barley-water  in 
equal  proportions,  and  to  take  as  medicine,  powders  of  bismuth  and  aro- 
matic chalk.  After  each  motion  she  was  bathed  in  cold  water.  After  six 
of  these  baths,  each  of  which  had  greatly  reduced  the  temperature,  the 
bodily  heat  remained  normal,  the  stools  were  reduced  to  three  in  the 
twenty-four  hours,  and  the  child's  appearance  was  much  improved.  She 
looked  brighter,  the  eyes  were  less  hoUow,  and  there  was  less  lividity 
about  the  lips.  The  stools  were  green  and  slimy,  and  were  evacuated  with 
straining.  Unfortunately,  after  a  few  days  of  this  improvement,  although 
there  was  no  increase  in  the  diarrhoea,  the  child  seemed  to  sink  from  ex- 
haustion, and  died  on  the  nineteenth  day  of  the  illness. 

In  this  and  similar  cases,  the  child  was  placed  in  cold  water,  and  bathed 
for  a  minute  or  two  with  a  sponge.  When  the  child  is  very  weak,  it  is  ad- 
visable to  make  use  of  water  warmed  to  the  temperature  of  70°,  and  to 
bathe  him  in  this  water  for  a  few  minutes,  or  until  sufiicient  evidence  of 
reduced  temperature  is  obtained.  Afterwards,  he  should  be  placed  between 
blankets  in  his  cot,  with  a  hot  bottle  to  his  feet.  A  stimulant  is  usually 
required  after  the  bath  ;  and  may  be  given  with  advantage,  also,  when  the 
child  is  taken  out  of  his  cot  to  be  placed  in  the  water. 

The  above  measures  are  all  of  great  importance,  and  constitute  in  them- 
selves the  main  treatment  of  the  disease.  The  use  of  drugs,  although  often 
of  signal  service  in  the  conduct  of  the  case,  cannot  be  expected  to  lead  to 
any  good  result  unless  the  other  matters  have  been  first  attended  to. 

If  the  case  is  seen  early,  it  is  well  to  begin  the  medicinal  treatment  with 
a  gentle  laxative,  such  as  castor-oil,  or  rhubarb  and  soda.  Afterwards,  if 
the  temperature  is  only  moderately  elevated,  not  passing  above  100°  in  the 
rectum,  the  aperient  should  be  followed  by  an  astringent  mixture  containing 


DISEASE   IlSr   CHILDEEIf. 

opium.  For  a  child  of  six  months  old,  two  grains  of  the  extract  of  hsema- 
toxylon  may  be  combined  with  five  drops  of  the  tincture  of  catechu,  and 
half  a  drop  of  laudanum  in  a  chalk  mixture,  and  given  every  six  hours 
in  the  day  and  night.  If  the  case  resist  this  treatment,  it  usually  goes  on, 
and  appears  to  be  little  influenced  by  astringents,  however  ingeniously  they 
may  be  varied  and  combined.  The  cases  we  meet  with  in  children's  hos- 
pitals, have  usually  been  treated  with  a  variety  of  the  ordinary  binding  rem- 
edies, but  the  diarrhoea  continues  apparently  unaffected  by  changes  in  the 
physic.  After  seeing  many  of  these  cases,  we  are  led  to  rely  less  upon  the 
pharmacopoeia  than  upon  attention  to  diet  and  the  other  means  by  which 
the  disorder  may  be  controlled.  Of  astringent  remedies  I  prefer  the  ex- 
tracts of  hasmatoxylon  (gr.  ij.-v.),  and  rhatany  (gr.  ij.-v.) ,  or  the  tincture 
of  catechu  (TTl  v.-x.),  to  gallic  acid,  sulphuric  acid,  and  lead.  In  my  hands, 
dilute  sulphuric  acid  has  appeared  to  be  almost  inert  unless  given  in  a  fair- 
ly concentrated  form  ;  gallic  acid  is  often  disappointing  as  a  cure  for  diar- 
rhoea, and  lead  I  believe  to  be  inadmissible  for  infants,  as  it  has  seemed  to 
me  to  be  not  unfrequently  a  cause  of  convulsions. 

In  cases  which  resist  the  ordinary  astringents,  the  old  prescription  of 
dilute  nitric  acid  with  opium  is  often  of  special  value.  For  a  child  of  six 
months  old,  two  drops  of  the  dilute  acid,  with  half  a  drop  of  tinct.  opii,  may 
be  combined  with  a  quarter  of  a  drop  of  tinct.  capsici,  or  two  of  tinct. 
zingiberis,  and  given  in  a  teaspoonful  of  water  sweetened  with  glycerine, 
three  times  a  day.  When  the  diarrhoea  is  accompanied  by  a  high  temper- 
ature, astringents  are  seldom  of  much  service  until  the  pyrexia  has  subsided. 
In  these  serious  cases,  the  temperature  must  first  be  reduced  by  cool  or 
tepid  bathing ;  and  for  medicine,  the  child  may  take  a  few  drops  of  castor- 
oil  (TTj,  iij.-vj.,  according  to  his  age),  with  one  or  two  drops  of  laudanum, 
several  times  in  the  day.  Another  remedy,  from  which  the  best  results  some- 
times follow,  is  ipecacuanha.  The  value  of  ipecacuanha  in  small  and  re- 
peated doses  in  the  bowel  complaints  of  children,  has  long  been  known. 
Certainly,  there  are  few  drugs  which  have  a  more  striking  effect  upon  the 
mucous  membrane  of  the  intestine.  The  dose  of  ipecacuanha  should  always 
be  combined  with  an  aromatic.  One-tenth  or  one-eighth  of  a  gTain  may  be 
given  with  a  few  grains  of  aromatic  chalk  powder  in  mucilage  every  three 
or  four  hours.  Even  in  these  small  doses,  the  remedy  may  sometimes  ex- 
ercise a  depressing  effect  upon  the  system  ;  it  is  well,  therefore,  to  combine 
with  each  dose  a  few  drops  of  chloric  ether  or  sal  volatile.  Another  form 
in  which  the  remedy  may  be  administered  is  the  time-honoured  combination 
of  Dover's  powder  with  mercury  and  chalk.  I  have  known  obstinate  cases 
.  of  inflammatory  diarrhoea,  which  had  resisted  other  methods  of  treatment, 
to  yield  quickly  to  small  and  repeated  doses  of  this  compound  powder. ,  To 
a  child  of  six  months  old,  I  order  a  quarter  of  a  grain  of  each  (Dover's  pow- 
der and  gray  powder)  every  three  hours.  Ipecacuanha  is  also  useful  in 
somewhat  larger  doses,  so  as  to  produce  a  slight  emetic  action.  Given  in 
quantities  of  half  a  grain  or  a  grain  to  a  child  of  six  months  old  twice  in  the 
day,  it  will  often  produce  vomiting  without  much  retching  ;  and  if  the 
stools  have  been  previously  pasty  and  sour-smelling,  wiU  cause  a  very  rapid 
improvement  in  their  character.  When  the  lower  bowel  is  affected,  and 
there  is  great  tenesmus,  ipecacuanha  is  especially  indicated.  In  such  cases, 
it  may  be  administered  suspended  in  thin  starch  (gr.  v.  to  3  ij.)  as  an  injec- 
tion twice  a  day.  The  castor-oil  and  opium  mixture  is  also  useful  where 
the  lower  bowel  is  the  seat  of  catarrh,  and  has  great  influence  in  allaying 
the,  pain  and  tenesmus.  One-eighth  of  a  grain  of  powdered  ipecacuanha 
may  be  usefully  combined  with  this  mixture.     If  the  stomach  it;  very  irri- 


I]^7FLAMMAT0RY   DIAEEIICEA — TEEATMENT.  639 

table,  and  the  diarrhoea  is  accompanied  by  excessive  vomiting,  ipecacuanha 
is  of  the  utmost  service.  This  drug,  although  an  emetic  in  large  doses,  in 
feeble  doses  is  a  sedative  ;  and  if  given  very  frequently  in  small  quantities, 
has  a  very  striking  influence  in  improving  the  condition  of  the  patient.  In 
fact,  fully  to  exhibit  the  value  of  this  remedy,  we  should  select  a  case  in 
which  the  vomiting  is  frequent  and  the  tenesmus  distressing,  and  give  one 
or  two  drops  of  ipecacuanha  wine  in  half  a  teaspoonful  of  water  regularly 
every  hour.  Antimony,  which  has  a  similar  action  to  iiDecacuanha,  is  also 
useful  in  like  cases.  Two  drops  of  the  wine,  combined  with  half  a  ^rop  of 
opium,  and  two  or  three  of  tincture  of  ginger,  form  a  very  satisfactory  rem- 
edy given  every  four  or  six  hours.  In  all  cases  where  the  lower  bowel  is 
inflamed,  an  injection  of  tinct.  opii  in  thin  warm  starch  (TTl  iij.-v.  to  3  ss.)  is 
most  useful  in  relieving  the  tenesmus  and  checking  the  purging.  It  may  be 
administered  every  night.  Dr.  Tyson  recommends  chloral  to  be  used  in  the 
same  way,  and  prescribes  half  a  drachm  of  the  chloral  hydrate  to  two 
ounces  of  thin  starch.  Of  this,  one  drachm  is  to  be  used  at  a  time.  A  drug 
which  is  often  useful  when  other  astringents  fail,  is  bismuth  ;  but  to  be 
efficacious,  the  dose  of  this  drug  must  be  large.  For  a  child  of  six  months 
old,  it  will  be  useless  to  give  a  smaller  quantity  than  ten  grains  every  four 
hours.  I  usually  combine  the  bismuth  with  a  few  grains  of  the  aromatic 
chalk  powder,  and  have  often  met  with  very  good  results  from  this  remedy. 

Directly  a  reduction  in  the  temperatui'e  and  an  increase  in  the  consis'- 
ence  of  the  stools  show  that  the  first  acute  violence  of  the  disease  is  sub- 
siding, astringent  remedies  are  called  for,  and  the  case  must  be  treated  as 
already  described. 

If  the  lower  bowel  is  acutely  inflamed,  and  prolapses  as  a  crimson  baU 
which  cannot  be  returned,  or  is  replaced  with  great  difficulty,  the  protrud- 
ed gut  should  be  first  fomented  with  warm  water  ;  next,  half  an  ounce  of 
thin,  warm  starch,  containing  four  drops  of  laudanum  and  five  grains  of 
powdered  ii^ecacuanha,  should  be  thrown  up  the  rectum  ;  lastly^  a  thick 
poultice  of  boiled  starch  should  be  applied  over  the  fundament.  The 
enema  may  be  repeated  twice  a  day,  but  the  fomentation  and  poultice 
should  be  renewed  after  each  action  of  the  bowels.  If  prolajDSus  occur 
later,  as  a  consequence  of  relaxation  of  the  sphincter  and  irritability  of  the 
mucous  membrane  at  the  lower  part  of  the  rectum,  the  bowel  should  be  re- 
turned by  pressure  with  the  oiled  finger,  and  if  necessary  may  be  retained 
in  place  by  a  pad.  Astringent  and  tonic  remedies  internally,  such  as  jjer- 
nitrate  of  iron  and  nux  vomica  (for  a  child  of  six  months  old  :  liq.  ferri  per- 
nitratis,  TTL  iij.  ;  tinct.  nucis.  vomica?,  1U  ^  ;  aquam  ad.,  3  j. ;  to  be  taken  three 
times  a  day),  and  enemata  of  infusion  of  rhatany  after  each  protrusion, 
will  usually  quickly  put  an  end  to  the  jorolapse.  Ordinary  cases  of  pro- 
lapsus ani  in  children,  the  consequence  of  repeated  catarrhs  of  the  lower 
bowel,  without  any  great  frequency  or  urgency  in  the  dejections,  may  be 
readily  cured  in  most  cases  by  the  appHcation  of  an  efficient  flannel  binder 
to  the  belly.  The  occui-rence  of  fresh  catan-lis  being  thus  prevented,  the 
relaxed  mucous  membrane  soon  recovers  its  tone. 

In  cases  where  the  symptoms  known  as  "spurious  hydrocephalus"  are 
noticed,  or  in  any  case  where  signs  of  prostration  are  visible,  the  child 
should  be  placed  for  ten  minutes  in  a  warm  mustard  bath,  and  should  be 
afterwards  wrapped  in  flannel,  with  hot  bottles  to  his  sides  and  against  his 
feet.  The  brandy-and-egg  mixture  can  then  be  given  every  hour  or  half 
hour  in  doses  of  one  teaspoonful,  or  if  the  patient  be  a  young  infant  white 
wine  whey  may  be  used  instead.  In  all  cases  of  inflammatory  diarrhoea, 
the  quantity  of  food  to  be  taken  at  one  tirae  must  be  carefully  regulated 


640  DISEASE  IIST   CHILDRElSr. 

according  to  the  strength  of  the  child.  If  the  purgmg  be  severe,  and  espe- 
cially if  it  be  accompanied  by  distressing  vomiting,  liquid  food  should  be 
given  in  quantities  of  one  spoonful  every  half  hour.  Sometimes  no  more 
than  one  teaspoonful  can  be  borne  at  one  time. 

In  the  chronic  form  of  inflammatory  diarrhoea,  the  treatment  consists 
mainly  in  a  careful  regulation  of  the  food.  jVIilk  in  such  a  case  is  an  irri- 
tant poison  which  must  be  strictly  forbidden  ;  and  starches  are  digested 
with  difficulty,  and  must  be  very  sj)aringiy  allowed. 

In  the  insidious  beginning  of  the  disorder,  when  large  pasty  stools  are 
being  j)assed,  the  child,  if  an  infant,  should  be  fed  with  weak  veal-broth 
and  barley-water  in  equal  proportions  ;  whey  with  cream  ;  the  yolk  of  one 
egQ  beaten  up  with  broth  or  whey  ;  and  Mellin's  food  mixed  with  whey  or 
barley-water.  The  meals  should  be  frequently  varied  during  the  day,  and 
the  quantity  allowed  must  be  strictly  proportioned  to  the  infant's  powers 
of  digestion.  For  medicine,  he  may  take  a  powder  of  rhubarb  (gr.  ij.-iij.) 
and  aromatic  chalk  (gT.  iij.-v.)  every  night  for  three  nights  ;  and  in  the  day, 
a  mixture  composed  of  half  a  di'op  or  a  drop  of  laudanum  with  four  or  five 
grains  of  the  bicarbonate  of  soda  in  some  aromatic  water.  If  the  stools 
still  continue  pasty  in  character,  although  reduced  in  quantity,  a  couple  of 
grains  of  pepsin  may  be  given  two  or  three  times  a  d.Q.j  in  water  and  gly- 
cerine, before  food.  In  such  young  children,  if  the  derangement  have  not 
passed  beyond  this  early  stage,  it  is  usually  readily  arrested  by  this  means. 
The  infant  should  be  warmly  clothed,  with  a  flannel  bandage  round  his 
belly,  and  should  be  taken  out  frequently  into  the  open  air. 

In  older  childi'en,  if  the  derangement  have  persisted  for  a  considerable 
time,  digestion  and  nutrition  are  less  easily  restored.  The  same  plan  must 
be  adopted  of  forbidding  milk,  and  greatly  restricting  the  quantity  of  starchy 
food.  The  child  should  take  the  yolk  of  an  egg  for  his  breakfast,  with  a 
slice  or  two  of  thin,  well-toasted  bread  and  fresh  butter.  For  dinner,  the 
lean  of  an  under-done  mutton-chop,  with  well-boiled  cauhflower,  and  fried 
bread  crumbs.  For  his  evening  meal,  strong  broth,  meat- jelly,  or  meat-es- 
sence. It  is  best,  in  obstinate  cases,  to  accustom  the  child  to  take  malt  bis- 
cuits, or  malted  rusks,  instead  of  ordinary  bread  and  toast,  as  the  fonner 
are  much  more  readily  digested.  Sometimes  the  pancreatic  emulsion  seems 
to  be  beneficial,  but  apart  from  the  disagreeable  taste  of  this  preparation, 
which  renders  it  exceedingly  unj)leasant  to  the  patient,  it  often  causes  nausea 
and  discomfort,  and  has  to  be  discontinued.  Pepsin  (gT.  iij.-v.)  is,  however, 
very  useful,  and  the  extract  of  malt  often  proves  a  valuable  aid  to  digestion. 
Still,  maltine  must  be  given  with  caution,  as,  if  it  contain  excess  of  glucose, 
it  may  encourage  looseness  of  the  bowels. 

I  have  found  raw  meat  of  immense  service  in  cases  where  the  stools 
continue  pasty  and  offensive  in  spite  of  the  most  careful  regulation  of  the 
diet.  It  is  prepared  by  mincing  a  piece  of  raw  rumjJ-steak  or  mutton-chop, 
pounding  it  finely  in  a  mortar,  and  then  straining  through  a  fine  sieve. 
Meat  so  prepared  may  be  eaten  as  it  is,  or  diffused  through  meat-broth  or 
meat-jelly,  or  sjjread  upon  bread  and  butter.  It  may  be  taken  in  large  quan- 
tities. If  possible,  the  child  should  be  induced  to  ^wallow  from  a  quarter 
to  half  a  pound  in  the  coui'se  of  the  day.  Before  each  meal  of  raw  meat,  a 
dose  of  pepsin  should  be  administered.  Childi-en  soon  take  a  liking  for 
this  food.  At  first  it  is  only  partially  digested,  and  the  decomposing  resi- 
due, gives  a  most  offensive  smeU  to  the  stools;  but  after  a  few  days,  es-  ' 
pecially  if  pepsin  be  taken,  the  meat  ceases  to  be  visible  in  the  motions. 
By  the  above  measures,  strictly  carried  out,  the  most  obstinate  cases  can  be 
arrested.     The  child  raj^idly  regains  flesh  and  strength,  and  after  a  time 


INFLAMMATOEY   DIAERH(EA — TEEATMENT.  641 

Ms  power  of  digesting  milk  and  starcli  returns.  Very  careful  watching, 
however,  is  required  in  order  to  carry  the  illness  to  a  successful  issue.  The 
stools  must  be  inspected  every  day,  and  any  sign  of  looseness,  offensiveness, 
or  hyper-secretion  of  mucus  will  require  to  be  promptly  attended  to.  Of- 
fensiveness of  the  motions  is  due  to  the  presence  in  them  of  undigested  and 
decomposing  food.  This  is  often  the  consequence  of  abnormal  briskness  of 
peristaltic  action,  which  forces  the  contents  of  the  bowel  too  rapidly  along ; 
or  it  may  be  due  to  mere  weakness  of  digestive  power.  In  the  first  case,  one 
drop  of  laudanum  should  be  given  three  times  a  day  to  quiet  exaggerated 
peristaltic  action.  In  the  second,  the  diet  must  be  revised,  especially  in  the 
matter  of  farinaceous  food,  and  no  starch  unguarded  by  malt  should  be  al- 
lowed to  be  taken.  Excess  of  mucus  may  usually  be  quickly  moderated 
by  the  castor-oil  and  opium  mixture  previously  recommended,  or  by  a  few 
drops  (v.-x.)  of  liq.  hydrargyri  perchloridi,  given  every  two  or  three  hours, 
during  the  day.  Slight  looseness  of  the  bowels  is  readily  arrested  by 
■nightly  doses  of  powdered  rhubarb  (gr.  iij.-v.)  and  aromatic  chalk-powder 
(gr.  v.-viij.) ;  or  the  latter  may  be  given  with  a  drop  of  laudanum,  and  ten  or 
fifteen  of  tinct.  catechu,  three  or  four  times  in  the  day.  The  flannel  binder 
in  all  these  cases  is  as  important  for  older  children  as  it  is  for  infants,  and 
should  be  fitted  closely  to  the  abdomen,  as  already  directed. 

If,  when  the  child  is  first  seen,  the  derangement  has  become  a  confirmed 
diarrhoea,  the  above  plan  of  treatment,  as  regards  diet,  must  still  be  the 
same.  The  belly  should  be  covered  with  cotton  wadding  under  a  flannel 
binder,  and  the  child  should  be  strictly  confined  to  two  rooms.  The  purg- 
ing must  be  controlled  by  hgematoxylon,  rhatany,  and  opium,  given  several 
times  in  the  day  in  the  doses  recommended  on  a  previous  page  ;  and  if 
the  motions  are  sour-smelling,  a  few  grains  of  aromatic  chalk  may  be  added. 
If  the  purging  is  obstinate,  especially  if  ulceration  of  the  bowels  is  sus- 
pected, nitrate  of  silver  is  a  most  valuable  remedy.  It  is  suitable  to  both 
infants  and  older  children,  and  should  be  given  with  dilute  nitric  acid  and 
tinct.  opii  in  glycerine.  For  a  child  of  six  months  old,  one-eighth  of  a  grain 
may  be  administered  every  four  hours.  For  an  older  child,  the  quantity 
of  the  nitrate  may  be  increased  to  one-fifth  or  one-fourth  of  a  grain.  The 
treatment  of  severe  cases  when  ulceration  of  the  bowel  is  present,  is  fully 
considered  in  another  place  (see  page  666). 

The  raw  meat  diet  is  very  useful  in  obstinate  cases,  and,  if  the  diarrhoea 
be  copious,  should  form  the  staple  of  the  child's  nourishment.  Stimulants, 
will  usually  be  required,  and  should  consist  of  the  brandy-and-egg  mixture 
given  as  often  and  in  such  quantities  as  may  seem  necessary. 

When  the  purging  has  been  arrested,  the  case  must  be  treated  as  de- 
scribed for  the  early  insidious  form  of  the  complaint.  Afterwards,  quinine 
and  iron  may  be  given,  and  the  child  should  be  sent,  if  possible,  into  a  bra- 
cing air.  A  valuable  tonic  in  these  cases  is  the  following,  suitable  for  a 
child  of  three  years  old : — 

3  •  Pepsini  porci , gi'-  iij- 

Liq.  strychniaj lU  ^ 

Quinise gr.  ss. 

Acidi  nitro-muriatici  dil   TTl,  iij. 

Aquam ad.  3  ij- 

M.  ft.  haustus. 

To  be  taken  before  each  of  the  three  principal  meals. 

Cod-liver  oil  is  also  a  useful  remedy,  and  should  never  be  neglected  in 
obstinate  cases. 
41 


CHAPTEE  YL 

CHOLERAIC   DIAERHCEA   (INFANTILE   CHOLERA). 

Choleraic  diarrhoea  is  the  most  dangerous  form  of  intestinal  flux  to  which 
children  are  liable.  It  occui's  only  during  the  summer  months,  runs  a 
very  rapid  course,  induces  in  a  few  hours  a  starthng  change  in  the  appear- 
ance of  the  patient,  and  often  ends  fatally.  The  affection  has  derived  its 
name  of  choleraic  dian'hoea  from  its  resemblance  in  many  of  its  symptoms 
to  Asiatic  cholera  ;  but  it  is  not,  like  the  latter  disease,  an  epidemic  malady, 
and  appears  to  be  essentially  distinct  in  its  nature,  although  in  many  re- 
spects so  apparently  similar. 

Causation. — Choleraic  diarrhoea  is  especially  a  complaint  of  warm 
weather,  and  summer  heat  must  be  looked  upon  as  a  powerful  predispos- 
ing cause  of  the  disease.  Other  agencies,  however,  must  come  in  as  excit- 
ing causes,  for  the  affection  is  not  common  in  country  places,  and  indeed 
is  rarely  seen  out  of  cities.  Injudicious  feeding,  bad  drainage,  and  the 
effluvium  arising  from  decaying  organic  matter  are  probably  auxiliary 
causes  which  have  a  notable  influence  in  exciting  this  as  well  as  the  other 
forms  of  gastro-intestinal  disorder.  Infantile  cholera,  as  its  name  impHes, 
is  a  disease  of  early  childhood,  and  is  more  common  during  the  first  six 
months  than  at  a  later  period  of  infancy.  It  is  said  not  often  to  be  met 
with  after  the  first  dentition  is  corapleted  ;  but  older  children  are  subject, 
like  adults,  to  attacks  of  cholerine  or  summer  cholera,  which  have  all  the 
characteristics  of  choleraic  diarrhoea  in  the  infant.  Boys  are  said  to  be 
more  subject  to  it  than  girls  ;  and  robust  children  are  attacked  by  the  com- 
plaint as  often  as  the  ailing  and  the  feeble. 

Morbid  Anatomy. — An  examination  of  the  intestinal  canal  iii  fatal  cases 
of  infantile  cholera  reveals  little  to  account  for  the  alarming  character  of 
the  symptoms  by  which  the  progress  of  the  disease  had  been  accompanied. 
A  patchy  redness  of  the  mucous  sui'face  may  be  visible,  but  often  this  is 
very  slight  and  incomplete.  Indeed,  it  may  be  absent  altogether,  and  in- 
stead of  red,  the  mucous  membrane  may  be  paler  and  more  bloodless  than 
natural.  The  glands  of  Peyer's  patches,  and  the  solitary  glands  of  the  large 
intestine,  often  stand  out  from  the  surface  like  little  translucent  projec- 
tions, and  sometimes  the  mucous  membrane  is  softened.  The  softening 
appears  to  be  a  secondary  lesion,  and  to  occur  as  a  consequence  of  the  pro- 
fuse serous  transudation,  which  is  one  of  the  main  features  of  the  illness. 
The  same  softened  state  of  the  mucous  membrane  is  often  seen  in  the 
stomach.  If  the  course  of  the  disease  is  very  rapid,  extensive  destruction 
of  the  epithehal  coating  has  been  noticed  in  the  gastro-intestinal  canal. 
The  organs  generally  are  anaemic.  The  brain  is  especially  bloodless,  and 
is  said  to  give  evidence  of  fatty  degeneration  and  oedema.  The  kidneys 
are  congested,  and,  according  to  Kjellberg,  may  be  sometimes  the  seat  of 
acute  parenchymatous  nephritis. 

Symptoms. — The  outbreak  of  the  disease  may  be  sudden  or  gradual. 


CHOLEEAIC   DIAKEHGEA — SYMPTOMS.  643 

Sometimes  it  bursts  out  as  g,  violent  attack  of  vomiting  and  purging,  whicli 
quickly  assumes  alarming  proportions,  and  the  child  speedily  passes  into  a 
state  of  collaj)se.  In  other  cases  it  begins  as  an  ordinary  purging,  but 
after  a  few  days  vomiting  occurs,  and  the  stools  assume  the  peculiar  watery 
appearance  which  is  so  characteristic  of  this  fatal  malady. 

However  it  may  have  begun,  the  disease  when  established  has  verj'  pe- 
culiar features.  There  is  obstinate  vomiting  and  very  persistent  diarrhoea. 
The  child  first  throws  up  the  contents  of  his  stomach,  and  all  fluid  or 
medicine  swallowed  instantly  returns.  Next,  the  ejected  matters  consist 
of  mucus,  thin  watery  fluid  tinged  yellow,  or  even  pui-e  bile.  The  stools, 
which  are  at  first  feculent,  thin,  and  offensive,  soon  lose  almost  all  trace  of 
ffecal  matter,  and  consist  of  a  copious  flow  of  serous  fluid,  which  soaks  into 
the  diaper,  and  when  evaporated,  leaves  nothing  but  a  faint  yellowish  stain 
upon  the  linen.  The  quantity  of  fluid  discharged  from  the  bowels  is  some- 
times extraordinary.  When  thus  serous,  the  stools  are  not  especially  offen- 
sive ;  they  have  not  the  horribly  foetid  odour  which  is  noticed  in  many  cases 
of  inflammatory  diarrhoea — an  odour  which  seems  to  cling  to  the  diaper, 
and  can  be  with  difficulty  washed  away.  The  number  of  the  stools  varies. 
Sometimes  twelve  or  fifteen  are  passed  in  the  twenty-four  hours.  In  other 
cases  the  bowels  act  less  frequently  ;  but  usually,  if  the  stools  are  separated 
by  a  longer  interval,  a  larger  quantity  of  fluid  is  discharged  on  each  occa- 
sion, so  that  the  abstraction  of  water  fi'oni  the  body  is  very  much  the 
same. 

As  a  consequence  of  the  profuse  drain  both  from  the  stomach  and  bowels, 
the  patient's  body  wastes  and  dwindles  with  a  rapidity  which  is  surj^rising. 
After  only  a^  few  hours,  the  eyes  grow  hollow  and  the  nose  sharp,  the 
cheeks  fall  in,  and  all  the  features  look  pinched  and  drawn.  If  previously 
well  nourished,  the  child's  flesh  loses  all  elasticity,  and  feels  soft  and 
doughy  to  the  touch.  The  abdominal  parietes  are  flaccid  and  sometimes 
shrunken.  The  skin  is  inelastic.  Owing  to  the  loss  of  water,  the  thirst  is 
extreme.  The  child,  if  he  can  speak,  asks  constantly  for  drink.  If  an  in- 
fant, he  fixes  his  eyes  upon  any  cup  or  vessel  containing  fluid,  sucks  his 
lips,  and  whines  in  a  manner  which  is  sufficiently  expressive.  In  most 
cases,  however,  anything  which  may  be  swallowed  is  immediately  returned. 

The  urine  is  excessively  scanty,  and  if  the  diarrhoea  is  profuse,  may  seem 
to  be  almost  suppressed.  The  tongue  may  be  clean,  or  covered  with  a  thin 
fur.  Towards  the  end  of  the  disease  it  is  often  dry  and  brown.  The  pulse 
is  rapid  and  very  feeble.  It  often  reaches  150,  but  is  regular  in  rhythm. 
The  temperature  is  generally  high.  The  heat  of  the  surface  may  be  nat- 
ural, or  even  sub-normal,  and  often  the  extremities  feel  cold  to  the  hand  ; 
but  a  thermometer  placed  in  the  rectum  registers  a  high  level,  the  mercury 
rising  to  104°,  105°,  or  even  a  point  still  more  elevated.  The  child  is  ex- 
cessively restless.  As  long  as  he  has  strength  to  do  so,  he  moves  his  arms 
and  legs  uneasily,  and  whimpers  or  cries  feebly.  Often  he  draws  ujd  the 
comers  of  his  mouth  as  if  to  cry,  but  no  sound  is  heard.  He  sleeps  little, 
but  lies  in  a  drowsy  state  with  eyelids  only  partially  closed.  The  fontanelle 
is  deeply  hoUowed,  and  in  extreme  cases,  owing  to  the  shrinking  of  the 
brain  from  abstraction  of  water,  the  bones  of  the  skull  can  be  felt  to  over- 
lap. 

In  a  very  short  time,  unless  some  amendment  occur,  the  child  passes 
into  a  state  of  collapse.  He  lies  perfectly  quiet,  as  if  dosing.  His  eyes 
are  only  half  closed  ;  his  features  are  sharp,  and  his  face  livid  and  old- 
looking.  The  vomiting  usually  ceases  at  this  stage,  but  the  diarrhoea  gen- 
erally continues,  although  with  diminished  violence.     The  coma  becomes 


644  DISEASE   IN   CIIILDRElSr. 

more  and  moi^e  complete  ;  the  conjunctivse  cease  to  show  any  sign  of  sen- 
sitiveness, and  the  child  dies  quietly,  or  in  a  faint  convulsion. 

In  the  comparatively  rare  cases  which  terminate  favourably,  the  first 
sign  of  improvement  usually  noticed  is  a  fall  in  the  temperature  ;  the  next 
a  cessation  of  the  vomiting,  so  that  fluids  can  be  retained  upon  the  stomach. 
Then  the  stools  begin  to  present  a  better  apj)earance.  The  serous  discharge 
becomes  again  tinged  with  faecal  matter,  and  the  craving  for  drink  is  less 
noticeable.  The  diarrhoea  may  then  cease,  or  thin  feculent  stools  may  con- 
tinue to  be  passed  in  small  quantity  for  some  days.  In  other  cases  the  im- 
provement in  the  stools  is  the  earliest  sign  of  amendment,  and  the  vomiting 
continues  for  a  time,  even  after  the  purging  has  ceased. 

The  duration  of  the  iUness  is  terribly  brief.  Often  it  may  be  measured 
by  hours.  Always  at  the  end  of  the  fourth  or  fifth  day,  the  patient  is  either 
dead,  or  is  evidently  advancing  towards  convalescence.  Death  may  take 
place  in  five  or  sis  hours  from  the  first  onset.  In  other  cases  the  child 
survives  for  a  longer  period.  Usually  he  dies  in  the  course  of  the  third 
day. 

Diagnosis. — There  is  no  difficulty  about  the  detection  of  the  disorder. 
The  uncontrollable  vomiting  and  diarrhoea,  the  intense  thirst,  the  rapid 
shrinking  of  the  tissues,  the  copious  serous  stools,  the  scanty  secretion  of 
urine,  and  the  early  collapse — all  these  form  a  group  of  symptoms  which  is 
very  characteristic,  and,  indeed,  can  hardly  be  mistaken. 

Prognosis. — When  the  disease  is  established,  the  prospect  of  recovery 
is  faint.  Early  cessation  of  the  vomiting  is  a  favourable  sign,  and  any  re- 
turn of  feculent  matter  in  the  stools  allows  room  for  hope,  however  unfa- 
vourable the  general  condition  of  the  child  may  appear.  Also,  a  fall  in  the 
internal  temperature,  although  the  symptoms  may  not  have  ■vdsibly  im- 
proved, is  a  sign  of  amendment  which  is  not  to  be  disregarded.  If  the 
child  sink  into  a  state  of  collapse,  he  almost  invariably  dies.  At  any  rate, 
I  have  never  known  an  infant  to  recover  from  such  a  condition.  Indeed, 
in  any  case,  during  the  first  few  months  of  life,  the  ratio  of  recoveries  is 
excessively  small. 

Treatment. — On  account  of  the  persistent  vomiting,  which  is  one  of  the 
marked  symptoms  of  the  complaint,  attempts  to  supply  nourishment  and 
support  the  strength  of  the  child  against  the  exhausting  and  continuous 
drain  from  which  he  is  sufiering,  often  meet  with  little  success.  Indeed, 
as  long  as  the  vomiting  is  frequent  and  distressing,  and  the  purging  severe, 
it  is  better  to  abandon  all  attempts  to  introduce  food  into  the  stomach. 
We  should  content  ourselves  with  allowing  the  child  to  drink  as  much 
iced  water  as  he  shows  an  inclination  to  swallow  ;  for  stinting  of  liquid  in 
these  cases  has  been  shown  to  be  not  only  cruel,  but  injudicious.  -As 
soon  as  any  diminution  in  the  vomiting  allows  us  to  hope  that  food  may 
be  retained,  we  may  begin  by  giving  a  teaspoonful  of  white  wine  whey 
(iced),  and  repeating  this  quantity  every  twenty  minutes  or  half  hour.  If 
this  be  vomited,  a  less  quantity  should  be  given  ;  but  if  this,  too,  be  re- 
jected, it  is  better  to  postpone,  for  the  time,  any  further  attempts  to  sup- 
ply nourishment  and  return  to  the  iced  water.  If  the  stomach  can  retain 
the  whey,  the  child  may  be  allowed  to  take  it  in  considerable  quantities, 
sucking  it  through  the  bottle  like  any  ordinary  food.  If  after  a  few  hours 
there  is  no  sign  of  sickness,  a  dessertspoonful  of  cream  may  be  shaken  up 
in  the  bottleful  of  whey.  Milk  in  any  shape,  even  breast-milk,  must  be 
strictly  forbidden  in  these  cases. 

Koumiss  has  been  strongly  recommended  as  a  food  in  this  disease. 
Dr.  Archibald  M.  Campbell,  of  New  York,  speaks  higlily  of  its  value  in 


CHOLEEAIC   DIAREHCEA — TREATMENT.  645 

arresting  the  vomiting,  subduing  the  thirst,  reducing  the  number  of  the 
stools,  and  improving  their  appearance.  He  recommends  that  it  should 
be  given  at  first  in  quantities  of  half  or  a  whole  teaspoonful  every  ten 
minutes  or  quarter  of  an  houi',  and  that  the  quantity  should  be  gradually 
increased.  While  it  is  being  taken,  iced  filtered  water  can  still  be  used 
to  quench  thirst.  If  the  white  wine  whey  be  employed,  no  other  stimulant 
is  required ;  but  if  koumiss  be  used,  the  child  will  require  an  occasional 
dose  of  pure  brandy,  of  Avhich  five  or  ten  drops  may  be  given  at  one 
time. 

On  account  of  the  early  occurrence  of  collapse,  the  case  should  be 
watched  with  the  utmost  attention,  and  any  sign  of  exhaustion  requires  to 
be  combated  by  energetic  stimulation.  The  child  must  be  placed  for  five 
or  ten  minutes  in  a  warm  mustard  bath  ;  and  afterwards  brandy  (ten  to 
thirty  drops)  must  be  administered,  and  repeated  at  short  intervals,  until 
the  warmth  of  the  extremities  is  restored.  It  must  be  remembered  that  a 
high  internal  temperature  is  compatible  with  considerable  coldness  of  the 
surface  ;  and  that  it  is  of  extreme  imjDortance  to  encourage  the  heart's  ac- 
tion and  improve  the  general  circulation.  Often  the  dose  of  brandy  will 
have  to  be  repeated  every  few  minutes  for  a  time.  It  is  astonishing  how 
large  a  quantity  of  spirit  must  be  given  in  many  cases  to  produce  a  suffi- 
cient effect  even  upon  a  young  baby. 

If  the  child  is  seen  early,  before  exhaustion  has  come  on,  and  the  tem- 
perature is  found  to  be  high,  it  is  well  to  reduce  the  pyrexia  by  placing 
the  child  in  water  of  75°  or  80°  Fahr.  If,  however,  there  is  great  feeble- 
ness, the  mustard-bath  must  be  used  as  already  described. 

Medicines  given  by  the  mouth  are  very  disap^Dointing  in  this  disease. 
French  authors  speak  highly  of  the  value  of  nitrate  of  silver.  If  this  salt 
be  employed,  it  may  be  given  in  quantities  of  gr.  y^^  to  gr.  ^  several  times 
in  the  day.  A  common  prescription  is  a  combination  of  bismuth  with 
aromatic  chalk  powder.  If  used,  the  dose  of  bismuth  should  be  a  large 
one  (gr.  v.-x.  for  a  child  of  three  months  old),  but  the  medicine  is  usually 
vomited  ;  and  if  retained,  has  never  seemed  to  me  to  have  the  slightest 
effect  in  allaying  the  irritability  of  the  stomach  or  arresting  the  purging. 
The  use  of  the  salicylate  of  lime  has  been  proposed  by  Mr.  Walter  Kilner, 
and  the  value  of  the  remedy  has  been  very  warmly  praised  by  Dr.  Hutch- 
ings,  of  Brooklyn,  New  York,  in  the  treatment  of  these  cases.  This  physi- 
cian administered  the  drug  in  doses  of  from  three  to  five  grains  every  two 
or  three  hours.  If  a  small  dose  was  given  without  effect,  a  larger  one  was 
substituted  ;  and  the  influence  of  the  salt  in  controlling  the  purging, 
checking  the  vomiting,  and  reducing  the  temperature  was  very  decided. 
The  medicine  was  found,  in  most  cases,  to  arrest  the  stools  without  modify- 
ing their  character  ;  although,  in  exceptional  cases,  a  simple  diarrhoea  con- 
tinued for  a  short  time  during  convalescence.  Another  drug  to  which 
great  value  has  been  attached,  is  the  bromide  of  potassium.  It  is  said  in 
some  cases  to  produce  a  rapid  improvement  in  the  number  and  frequency 
of  the  stools. 

Enemata  are  sometimes  very  serviceable.  For  a  child  twelve  months 
old,  three  or  four  drops  of  laudanum  in  a  tablespoonful  of  thin  starch, 
with  a  quarter  of  a  grain  of  sulphate  of  copper,  may  be  thrown  up  the 
bowel.  The  injection  can  be  repeated  three  times  in  the  twenty-four 
hours,  and  will  be  sometimes  followed  by  signs  of  evident  amendment. 

In  my  experience,  by  far  the  most  valuable  remedy  is  morphia  admin- 
istered hypodermically.  The  sulphate  of  morphia,  as  being  less  likely  to  be 
converted  into  apo-morphia  in  the  blood,  is  recommended  by  Dr.  W.  Hard- 


646  DISEASE  iisr  children. 

man  for  this  purpose.  The  quantity  employed  need  not  be  large  ;  in  fact, 
a  small  dose  appears  to  be  nearly  as  effective  as  a  large  one.  For  a  child 
of  a  year  old,  one-thirtieth  of  a  grain  may  be  used,  combined  with  five  or 
six  drops  of  ether  ;  and  the  injection  may  be  repeated  in  an  houi"'s  time  if 
the  symptoms  continue.  This  treatment  is  best  suited  to  cases  which  are 
seen  early,  before  symptoms  of  exhaustion  have  set  in.  In  such  cases  the 
effect  of  the  sedative  so  introduced  is  to  arrest  the  vomiting  and  purging 
almost  immediately,  without  producing  any  signs  of  narcotism.  The  child 
afterwards  requires  energetic  stimulation  to  help  him  out  of  the  state  of 
weakness  into  which  he  has  fallen.  An  infant  should  be  fed  with  white 
wine  whey.  An  older  child  can  take  the  brandy-and-egg  mixture  in  fre- 
quent doses  ;  and  it  is  very  important  to  keep  the  extremities  warm.  In 
many  of  these  cases,  after  tbe  arrest  of  the  more  pressing  symptoms,  very 
vigilant  and  intelligent  nursing  is  required  to  enable  the  child  to  resist 
successfully  the  depressing  effect  of  the  illness.  Often  there  appears  to 
be  a  tendency  to  failure  of  the  heart's  action.  After  making  a  step  or  two 
towards  recovery,  the  patient  may  fall  back  again  into  a  state  of  asthenia, 
and  die,  without  any  return  of  the  gastro-intestinal  symptoms,  or  the  oc- 
currence of  any  inflammatory  complication  to  explain  the  unfavourable 
change.  This  tendency  must  be  combated  by  mustard-baths,  stimulating 
frictions  to  the  skin,  and  brandy  given  in  frequent  doses.  A  strong  mus- 
tard-poultice, placed  for  a  few  minutes  over  the  heart,  is  often  of  service  ; 
and  the  subcutaneous  injection  of  ether  may  prove  a  valuable  stimulant. 
In  addition  to  the  above  measures,  the  belly  must  be  covered  with  cotton 
wadding,  and  the  air  of  the  room  should  be  kept  pure,  and  frequently  re- 
newed. 

In  the  attacks  of  choleraic  diarrhoea  or  summer  cholera  which  occur  in 
older  children,  the  use  of  morphia  hypodermically  is  equally  valuable.  A 
sixteenth  or  twelfth  of  a  grain  may  be  used,  and  improvement  follows  very 
quickly. 

A  little  girl,  aged  seven  years,  was  seized  at  1  a.m.  with  violent  vomit- 
ing and  purging.  The  bowels  acted  very  frequently,  without  any  strain- 
ing, and  the  stools  consisted,  after  the  first  few  evacuations,  of  thin  serous 
fluid.  The  vomiting  continued.  The  child  looked  pinched  and  blue,  and 
was  excessively  feeble.  When  seen  at  4  a.m.,  the  surface  was  cold,  and  no 
pulse  could  be  felt  at  the  wrist.  The  stools  had  the  appearance  of  faintly- 
tinged  water.     The  thirst  was  intense. 

One-sixteenth  of  a  grain  of  morphia  was  at  once  administered  sub- 
cutaneously,  and  the  child  was  put  to  bed  with  a  hot  bottle  to  her  feet. 
The  diarrhoea  then  ceased,  and  although  the  vomiting  recurred  three  times 
afterwards,  it  was  each  time  excited  by  the  swallowing  of  milk.  At  9  a.m. 
the  temperature  was  100.4°,  and  a  few  hours  afterwards — eleven  houi's 
after  the  injection — it  was  noted  :  "  Condition  greatly  improved  ;  much 
stronger ;  some  blueness  about  mouth  ;  eyes  sunken  ;  tongue  slightly 
furred,  not  dry  ;  still  excessively  thirsty  ;  complains  of  no  pain  ;  pulse 
fairly  good,  138."  After  this  note,  the  child  only  vomited  once  or  twice, 
and  the  bowels  only  acted  on  two  occasions,  the  stools  each  time  being 
thin  and  offensive.     The  patient  was  soon  convalescent. 

The  diarrhoea  which  sometimes  succeeds  to  an  attack  of  infantile 
cholei-a,  must  be  treated  as  directed  under  the  head  of  Inflammatory 
Diarrhoea. 


CHAPTEK  YII. 

DYSENTERY. 

Dysentery  must  not  be  confounded  with  the  acute  catarrh  of  the  sigmoid 
flexure  and  rectum  which  is  so  common  in  children,  and  also  gives  rise  to 
severe  tenesmus  and  pain.  The  affection,  when  it  runs  its  ordinary 
course,  is  not,  strictly  speaking,  a  diarrhoea.  Faecal  matter  is  passed 
rarely,  and  then  only  as  small  hard  scybalous  masses  enveloped  in  mucus 
— stools  which  bear  no  resemblance  to  the  slimy  feculent  motions  which 
constitute  a  familiar  symptom  of  inflammatory  intestinal  catarrh.  True 
dysentery  is  a  specific  disease  which  often  occurs  in  epidemics,  although 
sporadic  cases  are  occasionally  met  with.  It  is  rarely  seen  in  England, 
except  in  the  chronic  form — the  result  of  a  previous  acute  attack  in  chil- 
dren who  had  been  resident  abroad. 

Causation. — Dysentery  is  common  in  tropical  climates,  especially  in 
places  which  are  badly  drained,  and  therefore  damp,  and  where  the  au'  is 
loaded  with  the  emanations  from  decaying  vegetable  matter.  On  account 
of  being  thus  endemic  in  ague-breeding  districts,  the  disease  has  been 
thought  to  have  some  affinity  with  intermittent  fever;  but  it  has  been 
shown  that  dysentery  is  not  necessarily  generated  in  malarious  spots,  and 
that  it  may  occur  in  places  where  ague  is  unknown.  Foul  air,  impure 
water,  bad  drainage  generally,  and  rapid  alternations  from  extreme  heat 
to  coolness  of  the  atmosphere  are  the  causes  to  which  the  disease  is 
especially  attributed.  In  a  case  which  was  under  my  care  in  the  East 
London  Children's  Hospital — a  little  boy  of  five  years  old,  in  whom,  after 
death,  the  mucous  membrane  of  the  whole  large  bowel  was  found  to  be 
converted  into  a  purplish- black  slough — the  illness  had  begun  suddenly 
during  very  hot  weather,  and  was  attributed  to  foul  emanations  arising 
from  the  emptying  of  the  dust-bins  of  the  street  in  which  he  was  living. 
It  is  well  known  that  amongst  the  poor  these  receptacles  are  charged  with 
refuse  of  every  kind,  and  are  often  most  offensive  from  the  presence  of  de- 
caying organic  matter.  Faulty  nutrition  and  chronic  digestive  derange- 
ments appear  to  be  predisposing  causes  which  may  incline  the  child  to  be 
more  readily  affected  by  the  injurious  influences  surrounding  him.  The 
disease  is  therefore  said  to  be  more  common  in  hand -fed  babies  than  in 
infants  at  the  breast.  The  aftection,  when  it  occurs  in  epidemics,  has  a 
tendency  to  propagate  itself.  The  emanations  given  out  by  the  dejections 
of  a  dysenteric  patient  are  said  to  possess  peculiarly  noxious  properties, 
so  that  any  one  incautiously  inhaling  the  efflu\ium  is  likely  to  take  the 
disease. 

Morhid  Anatomy.  — In  the  earhest  stage  of  dysentery  the  mucous  mem- 
brane of  the  colon  and  rectum  is  congested,  and  is  swollen  from  inflam- 
matory infiltration  into  its  substance  and  the  underlying  areolar  tissue. 
The  colour  of  the  membrane  becomes  rosy  red,  or  may  pass  through 
the  various  shades  of  purple  to  slate  gray  of  a  very  deep  tint.     At  the 


648  DISEASE  IN   CHILDEEN. 

same  time  tlie  solitary  glands  project  from  the  svu-face,  and  are  enlarged 
to  the  size  of  a  millet  seed  or  a  small  shot.  The  inflammation  sometimes 
occurs  in  patches,  which  are  separated  by  more  or  less  healthy-looking 
membrane,  and  these  run  together  so  as  to  cover  a  considerable  extent  of 
surface.  A  false  membrane  may  be  found  adhering  to  the  inflamed  area. 
This  can  be  separated  as  a  thin  opaque  film  which  dips  down  into  the  fol- 
Hcles  of  Lieberkiihn.  It  consists  of  an  inflammatory  hypei-plasia  of  the 
folhcular  ejDithehum. 

If  the  disease  pass  beyond  this  stage,  superficial  ulcerations  are  seen. 
Sloughs  form  upon  the  surface,  and  sepai'ate,  exposing  ragged,  hregular 
ulcers  with  swollen,  abruj^t  edges.  Dr.  Partes  was  of  opinion  that  the 
ulcers  began  in  the  distended  fohicles.  Dr.  Maclean  beheres  that  they  are 
produced  by  sub-mucous  piu-ulent  effusion  which  detaches  the  mucous 
membrane.  This  becomes  gangrenous  and  is  thi'own  off.  The  sloughs 
vary  in  size.  If  the  process  is  rapid,  large  sloughs  may  be  detached,  and 
sometimes  casts  of  the  intestinal  tube  are  eliminated  unbroken.  Their 
tint  is  yellow  or  ash-coloured,  or  even  almost  black.  The  ulcers  are  cir- 
cular or  irregular  in  shape,  and  are  large  or  small  according  to  the  extent 
of  mucous  membrane  destroyed.  The  floor  of  the  ulcer  is  usually  formed 
of  the  sub-mucous  tissue,  but  the  lesion  may  extend  to  the  muscular  coat, 
or  may  even  perforate  the  bowel  as  in  typhoid  fever. 

The  destructive  process  is  most  intense  in  the  lower  pai-t  of  the  colon 
and  in  the  rectum  ;  but  the  inflammation  may  involve  the  whole  colon,  and 
even  pass  the  iho-cgecal  valve  into  the  lower  part  of  the  ilium.  If  the 
child  survive,  cicatrisation  may  occur.  A  fibrinous  exudation  is  thrown 
out  on  the  floor  of  the  ulcer,  and  becomes  graduaUy  organised. 

Lesions  may  be  foiind  in  other  organs.  The  mesenteric  glands  may 
be  swollen,  the  abdominal  organs  may  be  congested,  and  abscess  of  the 
liver  may  occui-.  In  a  httle  gh'l,  aged  three  years  and  a  half,  who  died  in 
St.  Bartholomew's  Hospital  under  the  care  of  Dr.  Andrew,  two  abscesses 
were  found  in  the  hver.  The  child  had  never  hved  out  of  England,  but 
had  suffered  for  two  months  from  an  attack  of  dysentery,  succeeding  to 
jDrolonged  diarrhoea  of  ten  months'  duration.  One  of  the  abscesses  was 
situated  in  the  right  lobe,  and  was  as  large  as  an  orange.  The  second,  no 
larger  than  a  filbert,  occupied  the  left  lobe.  In  the  neighbourhood  of  the 
abscesses  the  structui'e  of  the  liver  was  healthy.  The  whole  of  the  large 
intestine  was  extensively  ulcerated. 

The  chronic  form  of  dysentery  is  not  always  the  consequence  of  un- 
healed ulcers.  Still,  in  many  cases  ulceration  is  present.  In  advanced 
cases  the  intestinal  tube  may  be  atrophied,  with  complete  disappearance 
of  its  glandular  structui'es,  and  extreme  thinness  of  its  coats.  In  a  less  ad- 
vanced stage,  the  areolar  tissue,  and  even  all  the  coats  of  the  bowel,  may 
be  greatly  thickened. 

Symptoms. — The  illness  begins  with  shght  fever,  loss  of  appetite,  and 
■sometimes  nausea.  The  child  complains  of  uneasiness  in  his  belly  of  a 
colicky  character,  but  his  sufferings  do  not  seem  to  be  very  severe.  Then 
a  sudden  feehng  of  tenesmus  urges  him  to  evacuate  the  bowels,  and  the 
contents  of  the  rectum  are  discharged,  more  or  less  coated  v^dth  tenacious 
mucus.  The  passage  of  the  motion,  however,  produces  little  or  no  rehef. 
The  desire  quickly  returns,  so  that  the  child  almost  constantly  requh-es 
the  stool,  and  sits  straining  with  extreme  Aiolence.  Nothing,  however, 
is  voided  but  offensive  mucus,  with  occasional  minute  scybala.  The  mu- 
cus ma,y  be  streaked  or  mixed  more  or  less  intimately  with  blood.  In 
bad  cases,  it  resembles  a  rose-coloui-ed  jelly.     All  this  time  the  griping 


DYSENTERY — SYMPTOMS.  649 

continues.  The  cliild  often  screams  with  pain,  and  may  be  found  resting 
on  his  knees  in  his  bed,  with  his  head  buried  in  the  pillow.  Still,  there  is 
little  or  no  tenderness  of  the  belly.  The  face  is  pale,  with  a  distressed 
expression.  The  chUd  cannot  sleep.  His  tongue  is  white,  and  his  skin 
dry.  He  seldom  complains  much  of  thirst,  but  eats  little,  either  from  loss 
of  appetite,  or  from  the  increase  of  abdominal  pain,  which  he  soon  finds  is 
provoked  by  the  taking  of  food.  Sometimes,  for  the  fh'st  few  days,  the 
stools  may  continue  to  be  feculent.  Then,  as  the  griping  pains  and  te- 
nesmus increase,  the  dejections  become  more  scanty  and  frequent,  and 
consist  of  fsecal  matter  mixed  with  gelatinous  mucus. 

The  disease  does  not  always  begin  thus  mildly.  It  may  be  ushered  in 
by  a  severe  rigor,  or  an  attack  of  convulsions,  with  high  fever,  distressing 
griping  pains,  and  almost  constant  tenesmus.  There  is  burning  pain  at 
the  anus,  and  the  child,  if  permitted,  will  remain,  as  long  as  his  strength 
allows,  almost  constantly  seated  on  the  night-stool.  As  in  cases  of  acute 
inflammatory  diarrhoea,  the  straining  may  induce  prolapse  of  the  rectum. 
The  mucus  passed  from  the  bowels  is  bloody  almost  from  the  first ;  and 
sometimes  pure  blood,  bright  or  dark  and  clotted,  may  be  evacuated. 
However  it  may  have  begun,  if  the  disease  last  beyond  a  week  without 
improvement,  sloughy  matter  begins  to  be  discharged  from  the  bowels. 
The  stools,  instead  of  consisting  merely  of  offensive  bloody  mucus,  begin 
to  contain  dark-coloured,  shreddy  matter,  mixed  with  reddish,  dirty  water. 
The  odour  of  these  stools  is  intolerably  foetid,  and  grows  more  and  more 
insupportable.  The  particles  of  slough  generally  get  larger  in  successive 
dejections,  and  sometimes  cyhndrical  portions  of  dead  and  putrefying 
mucous  membrane  may  be  discharged  unbroken.  It  is  comparatively 
seldom,  however,  that  this  stage  is  reached  in  the  case  of  a  child.  The 
disease  is  so  exhausting  a  one  that  death  usually  takes  place  before  much 
sloughing  of  mucous  membrane  has  had  time  to  occur.  Sloughing  is 
rarely  found  in  children  under  twelve  years  of  age. 

The  abdomen  usually  becomes  distended  as  the  disease  progresses,  and 
there  is  often  some  tenderness  on  pressure  over  the  colon.  The  weakness 
now  becomes  very  great.  The  child  lies  back  with  a  pinched,  haggard 
face,  sleeps  little,  and  is  very  restless.  His  hands  and  feet  are  apt  to  be 
cold,  although  the  internal  temperature  is  high.  He  is  thirsty,  but  cares 
little  for  food.  He  may  be  troubled  with  vomiting.  His  water  is  scanty 
and  high-coloiored  ;  sometimes  it  is  passed  very  frequently,  but  retention 
of  urine  is  apt  to  occur,  and  require  the  use  of  a  catheter.  His  tongue, 
very  furred  on  the  dorsum,  becomes  red  at  the  tip  and  edges,  and  often  dry. 

In  favourable  cases  the  distressing  symptoms  gradually  subside.  The 
temperature  becomes  normal ;  the  tenesmus  grows  less  and  less,  and  dis- 
appears ;  the  stools  lose  their  blood  and  contain  much  grayish  mucus  ; 
they  begin  again  to  show  signs  of  feculent  matter;  the  insupportable 
dysenteric  odour  diminishes  ;  the  tongue  cleans,  and  the  appetite  and 
spirits  improve. 

Li  fatal  cases  the  abdomen  is  distended  ;  the  pulse  is  very  rapid  and 
feeble  ;  the  prostration  is  extreme  ;  the  face  is  dusky  and  haggard  ;  the  ex- 
tremities are  cold  ;  the  child  grows  dehrious,  or  sinks  into  a  state  of  stupor, 
in  which  he  dies.  Towards  the  end  paralysis  of  the  sphincter  may  occur, 
so  that  the  outlet  of  the  rectum  is  seen  wide  and  gaj^ing.  In  exceptional 
cases  oedema  of  the  lower  extremities  is  noticed  ;  and  Dr.  S.  C  Busey 
states  that  this  is  sometimes  associated  with  discoloui'ation  of  the  skin  of 
the  feet  and  legs. 

A  certain  variety  in  the  symptoms  can  be  noticed  in  different  cases. 


650  DISEASE   IX   CHILD  RElSr. 

Tlie  tenesmus  is  distressing  in  proportion  to  the  degree  to  wliich  the  rec- 
tum may  be  imphcated.  If,  as  may  hajDpen,  this  part  of  the  colon  is  only 
shghtly  involved,  the  straining  may  be  insignificant,  or  even  altogether  ab- 
sent. In  such  a  case  the  dejections  are  more  feculent,  and  contain  altered 
bile  mingled  with  the  mucus  and  blood.  The  number  of  the  stools  is  very- 
variable.  There  may  be  from  two  or  three  to  ten  or  twelve,  or  even  more, 
in  the  boui*.  In  the  latter  case,  even  if  the  cjuantity  of  mucus  discharged 
on  each  occasion  be  scanty,  the  whole  amount  passed  in  the  day  and  night 
may  be  very  considerable.  The  temperature  is  elevated.  The  mercuiy  in 
the  evening  is  often  found  to  rise  to  102°  or  103°,  but  sinks  in  the  morn- 
ing to  below  100°. 

If  the  child  die,  death  usually  takes  place  from  exhaustion,  the  patient 
being  worn  out  by  pain,  want  of  sleep,  and  the  profuse  discharge  of  a 
highly  albuminous  fluid  from  the  bowels.  Sometimes,  however,  the  fatal 
termination  may  be  reached  in  a  different  manner.  The  disease  may 
ap23ear  to  take  a  favourable  tui'u,  and  the  dysenteric  symptoms  may  have 
even  subsided,  when  the  child  is  suddenly  seized  with  convulsions,  then 
sinks  into  a  state  of  coma,  and  dies  in  a  few  hours.  Dr.  S.  C.  Busej-  has 
connected  these  cases  with  thrombosis  of  the  cranial  sinuses — a  comphca- 
tion  which  is  always  to  be  feared  in  the  infant,  when  his  strength  is  pro- 
foundly impaired  by  exhausting  disease. 

After  the  subsidence  of  the  acute  symptoms,  dysentery  often  passes 
into  a  chi'onic  stage.  The  child  remains  pale  and  thin,  and  continues  to 
lose  flesh.  His  bowels  are  open  several  times  in  the  day,  and  the  motions, 
which  consist  of  scybala  and  fleshy-looking  lumps,  are  passed  with  strain- 
ing. His  tongue  tends  to  be  diy,  and  is  often  glazed,  or  is  fissui-ed  with 
transverse  cracks.  He  complains  of  frequent  pains  in  the  belly  of  a  colicky 
char-acter,  and  these  are  usually  excited  by  taking  food.  The  child  is 
habitually  thii'sty,  and  is  sometimes  feverish  at  night.  Such  cases  may  go 
on  for  months,  or  in  older  children  for  years.  Even  in  the  most  favour- 
able cases,  convalescence  is  usually  slow,  the  bowels  being  costive  and 
troublesome  for  a  considerable  time  after  the  disease  is  at  an  end.  The 
colon  often  remains  torpid,  while  the  ii-ritability  of  the  rectum  continues  ; 
so  that,  although  the  aj^i^arent  need  of  evacuation  is  urgent,  and  the 
straining  distressing,  small  stools  consisting  of  scybala  embedded  in 
mucus  are  alone  discharged. 

Diagnosis. — As  long  as  the  stools  continue  to  be  feculent,  the  inflam- 
matory process  may  be  judged  to  be  as  yet  in  an  early  stage.  Afterwards, 
when  gelatinous  mucus,  clear  or  blood-stained,  is  passed  unmixed  with 
true  fceces,  or  containing  merely  hai'd  small  scybala,  we  may  conclude 
that  the  inflamed  area  is  still  limited  to  the  rectum  and  the  lower  part  of 
the  colon.  If  later,  when  the  tenesmus  and  gTijDing  pains  are  severe,  the 
mucus  is  again  contaminated  with  thin  feculent  matter,  it  is  probable 
that  the  inflammation  has  extended  higher  and  has  involved  the  upper 
part  of  the  colon,  and,  perhajDS,  a  portion  of  the  ihum. 

In  the  earliest  stage  there  appears  to  be  nothing  sjoecial  in  the 
symptoms  themselves  to  indicate  that  the  disease  is  anything  more  than 
an  ordinaiy  attack  of  severe  intestinal  cataiTh.  Afterwards,  Avhen  the 
affection  has  become  more  fully  developed,  the  characteristic  fcetor  of  the 
dejections  at  once  reveals  the  nature  of  the  illness.  Intussusception  of 
the  bowel  is  also  marked  by  the  passage  of  blood-stained,  non-feculent 
mucus,  combined  with  great  straining  and  severe  colicky  pain.  The  distin- 
guishing points  between  the  two  diseases  are  elsewhere  described  (see 
page  674). 


DTSEISTTEET — PEOGITOSIS — TREATMENT.  651 

Prognosis. — Tlie  danger  of  the  case  is  in  proportion  not  only  to  the 
severity  of  the  attack,  but  also  to  the  time  at  which  the  jDatient  comes 
under  observation.  Dysentery  is  a  disease  in  which  early  treatment  is  of 
the  utmost  importance.  If  the  child  be  seen  during  the  first  few  days,  or 
even  before  the  end  of  the  fu'st  week,  he  will  probably  recover  under 
judicious  treatment.  Absence  of  severe  depression  of  strength  and  spirits, 
placidity  of  exjoression,  and  a  fail-  pialse  are  all  signs  of  favourable  import ; 
and  an  early  return  of  feculence  in  the  stools,  if  combined  with  a  diminu- 
tion in  the  coheky  pains  and  tenesmus,  may  be  taken  as  an  indication  of  ap- 
proaching convalescence.  On  the  contrary,  early  prostration,  a  haggard 
facies,  a  feeble,  frequent  pulse,  great  restlessness,  hiccough,  a  dry  tongue, 
a  gangrenous  odour  from  the  stools,  and,  especially,  delirium — all  these 
symptoms  should  occasion  the  utmost  anxiety. 

'tl,  after  the  cessation  of  the  ordinary  dysenteric  symptoms,  the  child 
remain  prostrate  and  stupid,  lying  in  a  drowsy  state  with  eyes  only  par- 
tially closed,  his  puj)ils  sluggish,  his  breathing  irregular  or  of  the  Cheyne- 
Stokes  type,  we  should  fear  the  occurrence  of  cranial  thrombosis. 

Treatment. — If  the  child  is  seen  early,  he  should  be  put  into  a  bath  of 
the  temperatui'e  of  95°,  and  be  kept  there  for  ten  minutes,  or  a  less  time 
if  he  feel  faint.  He  should  be  then  put  into  bed  with  hot  fomentations 
to  his  belly,  and  take  a  di'aught  composed  of  castor-oil  in  conjunction  with 
rhubarb  and  laudanum,  in  some  aromatic  water.  This  combination  is 
believed  to  have  originated  with  the  late  Dr.  John  Scott,  examining  physi- 
cian to  the  H.  E.  I.  Company.  It  was  kindly  communicated  to  me  by  Dr. 
Chevers,  who,  in  his  own  large  Indian  experience,  has  been  accustomed  to 
rely  gTcatly  upon  this  remedy  if  given  sufficiently  early  in  the  disease. 
To  a  child  of  ten  years  of  age  the  draught  may  be  given  in  the  following 
proportions  : 

I^.  Tinct.  opii TTi  v. 

Olei  ricini, 

Tinct.  rhei  comp aa.  TT[  xl. 

Aquam  cassise ad.   3  ss. 

M.  ft.  haustus. 

If  after  this  draught  the  bowels  act  more  than  tvdce  in  the  next  twelve 
hours,  an  enema  containing  ten  drojDS  of  laudanum  in  half  an  ounce  of 
starch-  or  gum-water,  may  be  thrown  up  the  bowel.  In  the  case  of  childi'en, 
opium  should  be  used  with  especial  care,  on  account  of  the  early  prostra- 
tion which  is  so  apt  to  occur  in  this  disease.  If  given  at  the  fu-st,  its  use 
should  not  be  continued  too  long.  Dr.  Morehead  speaks  warningly  against 
a  too  prolonged  use  of  opium,  which  he  says  makes  the  dejection  pasty 
and  scant}',  and  is  injurious  to  favourable  progress. 

If  the  practitioner  fear  the  use  of  opium  b}'  the  mouth,  ipecacuanha  is 
as  useful  a  remedy  in  the  young  subject  as  it  is  in  the  adult.  Six  grains 
may  be  given  to  a  child  ten  years  of  age  ;  two,  three,  or  four  grains  to  a 
younger  child.  The  dose  must  be  mixed  with  as  little  fluid  as  possible, 
and  is  to  be  repeated  every  day  at  sufficient  intervals  for  the  child  to  be 
able  to  take  nourishment ;  for  the  ipecacuanha  must  not  be  given  until 
two  hours  have  elapsed  after  food.  Usually,  twelve  hours  may  be  per- 
mitted to  pass  between  successive  doses  of  the  drug.  The  diet  should 
consist  of  meat-broths,  thickened,  if  necessary,  with  boiled  sago  or  arrow- 
root ;  and  of  boiled  milk  diluted  with  barley-water,  and  alkalinised  with  a 
few  drops  of  the  saccharated  solution  of  lime.     The  child  must  be  kept 


652  DISEASE  IN   CHILDREN. 

as  quiet  as  possible  in  Ms  bed,  and  painful  tenesmus  must  be  treated  with 
injections  of  opium  and  starcli,  and  by  hot  applications  to  the  beUy  and 
anus.  All  through  the  acute  stage  the  child  shoiild  be  rigidly  confined  to 
his  bed.  The  air  of  his  room  should  be  kept  pure  by  open  windows  and 
the  projDer  use  of  disinfectants  ;  and  all  excreta  should  be  disinfected  be- 
fore removal  from  the  sick-chamber. 

If  the  case  is  seen  early,  or  is  of  a  comparatively  mild  character,  the 
above  treatment  will  be  usually  effectual  in  checking  its  further  develop- 
ment. In  the  very  severe  cases,  or  those  which  are  seen  after  the  end  of 
the  first  week,  when  gangrenous  sloughs  are  being  passed,  the  belly  should 
be  covered,  as  in  the  former  case,  with  hot  applications  or  turpentine 
stupes.  Ipecacuanha  should  be  then  given  in  one  full  dose  (gr.  vj.-viij.  to 
a  child  of  ten  years  of  age),  and  the  quantity  can  be  repeated  in  eight  or 
ten  hours.  If  thought  advisable,  a  few  drops  of  laudanum  can  be  given 
half  an  hour  before  the  ipecacuanha.  After  taking  the  latter  the  child 
should  be  kept  perfectly  quiet,  and  must  take  no  food  or  fluid.  If  he  be 
very  thirsty,  however,  he  may  be  allowed  to  suck  small  lumps  of  ice.  Dr. 
Maclean  speaks  very  highly  of  the  value  of  the  remedy  so  administered. 
According  to  this  physician,  the  straining  and  cohc  subside,  the  blood 
and  slime  disaj)pear  from  the  stools  and  are  replaced  by  feculent  matter, 
the  skin  becomes  moist,  and  the  patient  falls  into  a  quiet  sleep. 

The  value  of  mercury  in  the  treatment  of  dysentery  is  a  question  upon 
which  very  ojoposite  opinions  are  held.  While  some  writers  warmly  advo- 
cate its  use,  others  as  warmly  denounce  its  employment.  The  tendency 
of  the  present  day,  however,  appears  to  be  to  neglect  mercurials  in  favour 
of  ijDecacuanha.  Dr.  Morehead  was  accustomed  to  prescribe  a  combina- 
tion of  calomel  or  blue  piU,  ipecacuanha,  and  opium,  every  four,  six,  or 
eight  hours  ;  and  to  give,  in  addition,  a  small,  occasional  dose  of  castor-oU. 
This  treatment  he  considered  especially  applicable  to  the  first  few  days  of 
the  disease,  although  it  is  also  suitable  at  a  later  period.  He  relates  the 
case  of  a  child,  three  years  of  age,  who  had  been  ill  with  dysenteric  symp- 
toms for  eighteen  days.  Two  grains  of  ipecacuanha,  three  of  extract  of 
gentian,  and  one  each  of  Dover's  powder  and  blue  pill,  were  given  every 
three  hours,  with  great  benefit.  When,  after  a  few  days,  feculent  matter 
reappeared  in  the  stools,  the  opium  was  omitted  from  the  prescription, 
and  the  other  remedies  were  given  for  some  days  longer. 

Whether  mercury  be  given  according  to  this  method,  or  the  child  be 
treated  with  ipecacuanha  alone,  as  is  the  more  modern  practice,  an  occa- 
sional close  of  castor-oil  is  often  indicated.  If  the  abdomen  becomes  full 
and  tense,  and  the  dejections  are  scanty,  a  dose  of  the  oil  (two  teaspoonfuls 
to  a  child  ten  years  of  age)  may  be  given  with  advantage.  If  the  tenesmus 
is  distressing,  an  enema  of  starch  and  opium,  in  the  proportions  already 
recommended,  may  be  used  at  sufficient  intervals.  If,  towards  the  end  of 
the  disease,  the  child  appears  much  enfeebled,  the  brandy-and-egg  mix- 
ture should  be  given. 

In  the  case  of  an  infant,  the  treatment  varies  in  some  degree  from  that 
found  useful  in  older  children.  Ipecacuanha  is  not  to  be  recommended 
for  patients  under  twelve  months  old  ;  for,  according  to  ]Mi\  Scriven,  in- 
fants of  this  age  do  not  bear  well  the  nausea  and  starvation  which  this 
treatment  involves.  For  these  patients  calomel  is  a  preferable  remedy. 
To  a  child  eight  or  ten  months  old  half  a  grain  of  calomel  may  be  given 
morning  and  evening,  and  an  enema  containing  one  or  two  drops  of  laud- 
anum twice  in  twenty-four  hours.  Mr.  Scriven  speaks  highly  of  lancing 
the  gums  in  all  cases  of  dysentery  in  teething  infants.     He  disapproves  of 


DYSENTERY — TREATMENT.  653 

farinaceous  foods;  and  even  milk — unless  the  child  be  at  the  breast— he 
considerably  restricts  in  quantity,  preferring  to  rely  for  nourishment 
upon  beef-tea  and  chicken-broths.  As  in  the  case  of  other  forms  of  bowel 
complaint,  these  meat-broths  may  be  advantageously  combined  with  an 
equal  proportion  of  barley-water. 

In  no  instance  should  the  ordinary  astringent  remedies  be  used  while 
the  illness  is  acute ;  but  when  the  disease  passes  into  the  chronic  stage, 
they  may  be  judiciously  resorted  to.  In  such  cases,  large  doses  of  bismuth 
with  aromatic  chalk  may  be  given ;  rhatany  and  catechu  are  often  of  ser- 
vice ;  and  the  pernitrate  of  iron  is  an  especially  valuable  remedy.  Ene- 
mata  of  weak  nitrate  of  silver  (half  a  grain  to  the  ounce)  are  often  of  con- 
siderable value,  the  bowels  having  been  previously  cleared  out  by  a  copious 
injection  of  warm  water.  These  injections  should  be  large,  and  must  be 
given  very  slowly.  For  a  child  ten  years  old  a  couple  of  pints  may  be 
used.  Instead  of  a  nitrate  of  silver  injection,  simple  warm  water  may 
be  employed,  or  a  solution  of  alum  (gr.  xv,  to  the  ounce)  as  recommended 
by  Mr.  Scriven.  While  these  remedies  are  being  made  use  of  the  child 
should  take  a  daily  dose  of  Dover's  powder,  if  the  straining  and  abdom- 
inal pain  continue. 

Cases  which  have  resisted  treatment  by  astringents  will  sometimes 
yield  readily  to  ipecacuanha  in  doses  of  one  grain  three  times  a  day,  with 
an  occasional  injection  of  laudanum  and  ipecacuanha  in  warm  starch  if 
the  tenesmus  is  distressing.  At  the  same  time  the  food  should  consist 
of  strong  meat-essence,  well-boiled  rice,  pounded  under-done  meat,  and 
boiled  milk,  if  it  agree.     Eggs  are  often  not  well  borne  in  these  cases. 

A  remedy  which  is  very  useful  in  the  chronic  stage  of  dysentery  is  the 
perehloride  of  mercury  given  in  quantities  of  ten  or  fifteen  drops  several 
times  in  the  day.  It  may  be  usefully  combined,  as  Dr.  Ellis  has  sug- 
gested, with  the  tincture  of  cinchona.  Sometimes  the  perehloride  has 
been  found  to  be  more  useful  in  very  small  doses  frequently  repeated,  as 
five  drops  every  two  or  three  hours.  In  any  case,  if  the  dose  is  smaU  it 
must  be  repeated  more  frequently  in  the  day. 

In  all  cases  of  chronic  dysentery,  great  care  should  be  taken  that  the 
beUy  is  duly  protected  from  alternations  of  temperature  by  a  broad  flannel 
bandage,  that  every  attention  is  paid  to  promoting  the  action  of  the  skin, 
and  that  the  surface  of  the  body  is  kept  perfectly  clean.  A  complete 
change  of  climate  to  a  bracing  sea-air  is  of  the  utmost  service  in  complet- 
ing the  cure. 

During  convalescence  from  dysentery  the  child's  appetite  is  often 
enormous.  Great  watchfulness  must  be  therefore  used  that  he  do  not  eat 
a  quantity  of  indigestible  substances,  such  as  new  potatoes,  unripe  fruit, 
or  great  excess  of  farinaceous  matters  and  sweets.  He  should  live  prin- 
cipally upon  meat  once  cooked,  eggs,  fresh-made  broths  and  milk,  and 
wine,  in  the  shape  of  port  or  sound  claret,  may  be  allowed  him  with  his 
dinner. 


CHAPTER  YIII. 

GASTRO-INTESTINAL  HEMORRHAGE. 

H,TaroRBHAGE  may  occur  in  the  young  subject  l3otli  from  the  stomach  and 
bowels.  In  gastidc  haemorrhage  the  blood  may  be  vomited  dii'ectly  from 
the  stomach,  or  may  pass  down  the  alimentary  tnibe  and  be  voided  dark, 
and  more  or  less  altered  in  appearance,  "with  the  stools.  The  presence  of 
blood  in  the  evacuations  is,  therefore,  no  proof  that  the  source  of  bleeding 
is  in  the  bowels.  Nor,  indeed,  does  blood  ejected  from  the  mouth  always 
come  fi'om  the  stomach.  Even  blood  which  is  brought  up  by  evident 
retching,  and  intimately  mixed  with  cui'dled  milk,  may  not,  and  often  does 
not,  owe  its  origin  to  the  gastric  mucous  membrane.  Infants  at  the 
breast  not  unfrequently  vomit  blood  which  is  drawn  with  the  milk  from 
the  breast  of  the  mother.  Cracked  nipjDles  are  often  very  irritable,  and 
bleed  easily.  In  such  cases,  the  act  of  sucking  may  determine  a  haemor- 
rhage fi'om  the  fissiu'e,  and  a  large  quantity  of  blood  may  be  swallowed  by 
the  child.  At  the  end  of  the  meal  this  is  often  vomited  with  jDart  of  the 
milk  which  has  been  taken,  and  is  a  cause  of  great  alarm  to  the  parents. 

In  older  children  who  suffer  from  epistaxis,  the  blood  which  flows  down 
into  the  throat  fi'om  the  posterior  nares  is  almost  invariably  swallowed. 
If  this  be  large  in  quantity  it  is  sometimes  vomited,  and  appears  then  to 
have  been  thrown  out  by  the  stomach.  So,  also,  ulceration  of  the  back  of 
the  throat  and  of  the  gums,  such  as  is  seen  occasionally  in  scrofulous 
and  badly -nourished  children,  may  be  a  cause  of  bleeding.  If  at  the  same 
time  the  child  be  suffering  from  disordered  stomach,  and  vomiting  be 
frequent,  the  efforts  of  retching  may  determine  a  flow  of  blood  fi'om  the 
ulcerated  surface.  The  blood  mixes  -with  the  contents  of  the  stomach  as 
these  pass  through  the  mouth,  and  gives  the  appearance  of  hsemoiThage 
from  the  deranged  gastiic  membrane.  I  have  knoT^m  such  a  case  to  occur 
and  be  a  cause  of  great  perplexity. 

Causation. — Eeal  gastro-intestinal  heemoiThage  may  be  due  to  many 
different  conditions.  There  is  a  sj^ecial  form  of  haemorrhage  which  is 
occasionally  seen  in  new-born  infants  as  a  consequence  of  causes  which 
have  not  even  yet  been  fuUy  made  out.  Melcena  neonatorum  occurs 
usually  within  a  few  hours  of  birth.  It  is  said  to  be  more  common  in 
giiis  than  in  boys,  although  this  is  not  the  exj^erience  of  all  observers,  and 
stm'dy,  weU-nourished  children  are  as  amenable  to  it  as  the  feeble  and  the 
frail.  The  occurrence  is  fortunatety  very  rare.  Sometimes  it  has  been 
known  to  foUow  a  tedious  labour,  in  which  the  child's  head  had  suffered 
great  compression.  In  other  cases  the  respiratory  function  after  birth 
had  been  estabhshed  with  difficiilty.  Often,  however,  the  bleeding  can  be 
attributed  to  no  such  reason.  Sometimes  it  appears  to  be  the  direct 
result  of  ulceration  of  the  stomach  and  duodenum.  Such  a  lesion  has 
been  occasionally  discovered  in  the  new-born  babe,  and  has  been  ascribed 
to  follicular  gastritis  by  Billard;   to  an  embolism  of  the  umbilical  vein 


GASTK0-I:N^TESTINAL  H^MOERHAGE — CAUSATIOjST.  6dl 

near  tlie  liver,  and  extending  for  some  distance  into  its  branches,  by- 
Landau  ;  and  by  Steiner,  to  a  fatty  degeneration  of  the  blood-vessels. 
An  example  of  such  a  gastric  ulcer  was  shoT\ai  by  Dr.  Goodhart  in  1881, 
at  the  London  Pathological  Society.  A  new-born  infant  had  died  from 
hsematemesis  thirty  hours  after  its  birth.  The  child's  apiDearance  was 
healthy.  On  examination  of  the  body,  after  turning  out  the  blood-clot 
wth  which  the  stomach  was  distended,  a  small,  oval  ulcer,  one-eighth  of 
an  inch  in  length,  was  seen  at  the  cardiac  end  of  the  stomach  and  close  to 
the  greater  curvature.  This  sore  was  clean-cut,  sharp-edged,  and  firm  in 
texture.  In  its  floor  was  a  dark  speck,  which  proved,  on  close  insiDection, 
to  be  an  open  vessel.  It  is,  however,  uncommon  to  find  any  distinct 
breach  of  surface.  In  the  large  majority  of  cases  the  hsemorrhage  appears 
to  be  capillary,  and  nothing  but  a  congested  state  of  the  vessels  of  the 
stomach  is  discovered  on  examination  of  the  body. 

Some  writers,  especially  Grandidier  and  Kitter,  have  attributed  the 
bleeding  to  a  condition  allied  to  heemophilia  ;  and  certainly  in  cases  where 
death  results  from  profuse  capillary  hsemorrhage  in  the  new-born  child, 
some  special  and  unusual  tendency  to  bleed  from  slight  causes  must  evi- 
dently prevail.  In  one  of  four  cases  published  by  Dr.  Halliday  Croom,  a 
marked  heemorrhagic  tendency  existed  in  the  father.  In  another,  although 
no  family  predisposition  could  be  detected,  the  child  himseK  had  an  evi- 
dent tendency  to  bleed,  for  the  pressru-e  of  the  forceps  with  which  the 
infant  was  delivered  had  produced  an  extensive  ecchymosis  on  either  side 
of  the  head.  In  a  child  possessing  this  unfortunate  tendency,  any  cause 
which  interferes  with  the  estabhshment  of  respiration  will  increase  the 
pressure  on  the  veins,  and  may  thus  determine  an  effusion  of  blood  from 
the  capillary  system.  Still,  with  regard  to  this  supposed  constitutional  in- 
firmity", it  must  be  remarked  that  melaena  neonatorum  is  said  not  to  have 
been  especially  observed  in  famihes  subject  to  true  hsemophiha  ;  and  that 
of  infants  who  survive,  few  show  in  after  life  any  particular  tendency  to 
hsemorrhage. 

In  older  childi*en  gastro-intestinal  haemorrhage  may  be  due  to  either 
general  or  local  causes. 

Of  the  general  causes,  hsemorrhagic  purpura  is  perhaps  the  most  com- 
mon. In  this  disease  the  bleeding  occurs  not  only  from  the  stomach  and 
bowels,  but  also  from  the  nose,  mouth,  and  kidneys,  and  into  the  subcu- 
taneous tissue.  The  tendency  to  hsemorrhage  is  only  a  temjDorary  phe- 
nomenon, and  ceases  when  by  treatment  or  otherwise  the  condition  of  the 
patient  has  become  improved. 

In  hsemophiha  the  tendency  is  permanent,  and  persists  to  the  end  of 
life.  As  in  the  former  case,  the  bleeding  is  not  confined  to  the  gastric  or 
intestinal  mucous  membrane,  but  may  occur  from  any  mucous  siu-face  and 
into  the  sabcutaneous  tissue. 

In  the  malignant  forms  of  all  the  eruptive  fevers  general  hsemorrhage 
may  also  occui-.  In  such  cases  the  symptom  indicates  a  profound  con- 
tamination of  the  system,  and  is  of  most  unfavourable  augnrry. 

The  usual  form  of  gastro-intestinal  hsemorrhage  met  with  in  the  child 
arises  from  purely  local  causes.  Ulceration  of  the  bowels,  such  as  occurs 
in  typhoid  fever,  in  cases  of  long-standing  intestinal  catarrh,  and  as  a  con- 
sequence of  tubercular  or  scrofulous  disease,  is  a  common  source  of  bleed- 
ing. The  same  symptom  is  seen  in  the  ulceration  arising  from  dysentery. 
In  intussusception  a  prominent  feature  is  the  passage  of  blood  and  blood- 
stained mucus  from  the  bowel.  The  iiiitation  of  worms  will  sometimes 
induce  bleeding  from  the  mucous  membrane  ;  andintesfrnal  derangements 


656  DISEASE  IN   CHILDRElsr. 

which  give  rise  to  straining,  especially  if  the  bowel  prolapse,  are  a  common 
cause  of  admixture  of  blood  with  the  stools. 

There  is  one  other  cause  of  haemorrhage  which  must  be  mentioned. 
This  is  polj^us  of  the  rectum.  Polypi  are  said  not  to  be  uncommon  under 
the  age  of  ten  years,  and  to  occur  more  frequently  in  boys  than  in  girls. 
These  fibro- cellular  growths  spring  from  the  sub-mucous  tissue,  and  are 
covered  by  the  mucous  membrane.  They  are  more  vascular  in  the  child 
than  in  the  adult,  with  a  greater  tendency  to  bleed,  and  are  attached  by  a 
slender  pedicle  which  readUy  gives  way.  The  poly]3us  varies  in  size  from 
a  pea  to  a  marble,  and  may  be  sometimes  seen  within  the  bowel,  if  near 
the  sphincter,  looking  like  a  bright  red  cherry.  It  bleeds  easily,  both  dur- 
ing the  passage  of  a  stool  and  also  independently  of  defsecation,  and  if  its 
seat  is  near  the  outlet,  the  effused  blood  may  be  mixed  with  mucus. 

Symptoms. — In  the  case  of  the  new-born  baby,  the  haemorrhage  which 
is  special  to  this  period  of  life  begins  usually  within  a  few  days  of  birth — 
in  the  majority  of  instances  within  the  first  twenty-four  hours.  It  may, 
however,  be  delayed.  Of  fifty  cases  collected  by  Dr.  Croom,  the  bleeding 
took  place  : — in  thirty,  between  the  first  and  sixth  day  ;  in  eight,  between 
the  sixth  and  eighth  ;  in  fo,ur,  between  the  eighth  and  twelfth  ;  and  in 
eight,  between  the  twelfth  and  eighteenth  day.  The  blood  is  sometimes 
ejected  from  the  stomach  as  well  as  passed  from  the  bowels.  Sometimes, 
however,  melsena  occin-s  without  heematemesis  ;  and  less  commonly,  hsema- 
temesis  without  melsena.  Of  eight  cases  seen  by  Lederer,  four  had 
haemorrhage  from  both  stomach  and  bowels  ;  tkree  from  the  bowels  alone ; 
and  one  exclusively  from  the  stomach. 

The  appearance  of  the  blood  may  be  preceded  by  great  restlessness  and 
pallor,  a  sunken  beUy,  and  sudden  prostration.  "When  the  blood  appears 
externally  the  infant  seems  to  sufler  no  pain.  He  passes  apparently  an 
ordinary  stool ;  but  this,  on  inspection,  is  found  to  consist  either  of  dark 
treacly  matter  from  admixture  with  meconium,  or  of  dark  pure  blood.  If, 
at  first,  dark  and  contaminated  with  the  contents  of  the  bowels,  the  blood 
soon  becomes  red  and  unaltered.  In  quantity  it  is  often  sufficient  to  soak 
the  linen  and  the  diapers.  The  dejections  succeed  one  another  rapidly, 
and  after  each  passage  the  child  is  left  cold  and  motionless,  and  seem- 
ingly exhausted.  In  rare  cases,  if  the  discharge  is  sudden  and  copious, 
he  may  be  convulsed.  After  a  time  he  revives  somewhat,  and  cries  feebly  ; 
but  if  the  flow  be  j)rofuse,  soon  falls  into  a  coUapsed  state.  He  lies  quietly, 
with  pallid  face,  cold  extremities,  an  almost  imperceptible  pulse,  and  a 
sunken  fontanelle. 

After  continuing  for  about  twenty-four  hours,  the  haemorrhage,  if  the 
child  survives,  usually  stops.  In  most  cases  blood  ceases  to  be  ejected 
from  the  mouth  before  the  flow  from  the  bowels  is  at  an  end.  Sometimes, 
after  a  temporary  intermission,  the  bleeding  retui-ns,  and  may  continue,  in 
diminished  quantity,  for  several  days  longer.  When  the  bleeding  begins 
for  the  first  time  after  the  fall  of  the  cord,  haemorrhage  may  also  occur 
from  the  umbilicus.  Pale  watery  blood  oozes  from  the  navel,  and  the  flow 
persists  in  spite  of  all  efforts  to  arrest  it.  In  some  cases  the  effusion  of 
blood  is  confined  to  this  region,  but  more  commonly  it  is  quickly  followed 
by  haemorrhage  from  the  bowels,  and,  in  some  cases,  from  the  ears,  the 
gums,  the  vagina,  and  into  the  skin. 

If  the  haemorrhage  be  profuse  the  child  may  not  recover  from  the 
state  of  collapse  into  which  he  has  fallen.  In  the  favourable  cases  he 
gradually  improves,  but  remains  weakly  and  pallid  for  some  time  after- 
wards, with  a  tendency  to  intestinal  catarrh. 


GASTEO-IISTTESTINAL   H^MOERHAGE— DIAGISTOSIS.  657 

In  later  infancy  and  childhood,  gastro-intestinal  haemorrhage,  arising 
from  the  causes  which  have  been  mentioned,  usually  occurs  in  the  form  of 
melsena.  The  bleeding  is,  as  a  rule,  more  profuse  when  it  is  excited  by 
causes  acting  through  the  system  generally  than  when  it  occurs  in  conse- 
quence of  a  purely  local  lesion.  In  hsemorrhagic  purpura  large  quantities 
of  blood  may  be  passed  per  anum,  bright  red  and  clotted,  or  more  or  less 
altered  and  blackened.  In  this  disease,  as  also  in  hcemoj)hilia  and  in  the 
malignant  forms  of  the  specific  fevers,  the  tendency  to  haemorrhage  is  a 
general  one.  The  nose  and  gums  bleed  easily,  the  skin  is  spotted  with 
petechise,  or  larger  heemorrhagic  stains,  and  the  urine  is  often  discoloured. 

When  the  bleeding  occurs  from  local  causes  the  effusion  is  scanty,  as 
a  rule,  and  is  evacuated  from  the  bowel,  pure,  or  mixed  with  the  ordinary 
fsecal  dejections.  In  typhoid  fever  haemorrhage  is  the  exception  in  young 
subjects.  In  this  and  the  other  forms  of  intestinal  ulceration  the  bleed- 
ing, when  present,  is  seen  in  the  form  of  small  black  clots  at  the  bottom 
of  the  chamber-pan.  In  dysentery,  and  in  cases  of  invagination  of  the 
bowel,  the  blood  is  brighter,  and  is  passed  pure,  or  mixed  with  mucus.  It 
may  amount,  in  the  latter  disease,  to  several  ounces,  but  is  rarely  seen  in 
so  large  a  quantity.  Usually  only  a  few  teaspoonfuls  are  passed  at  a  tim^e, 
and  the  discharge  is  only  effected  with  excessive  straining  and  pain.  The 
irritation  of  worms  is  not  often  accompanied  by  bleeding,  but  in  rare 
cases  a  bright  red  clot  may  be  passed  per  anum.  Catarrh  of  the  lower 
part  of  the  colon,  especially  if  the  bowel  prolapse,  may  give  rise  to  slight 
hfemon'hage.  The  blood  is  usually  in  the  form  of  Ught-coloured  streaks, 
but  sometimes  small  red  lumps  may  be  evacuated. 

In  polypus  of  the  rectum  the  blood  is  also  bright  red,  and  may  be  in 
considerable  quantity — a  tablespoonful  or  more — pure,  or  mixed  with 
mucus.  If  the  growth  be  small  and  above  the  sphincter,  the  discharge  of 
blood  is  accompanied  by  no  pain  ;  but  if  it  be  large,  and  especially  if  it 
be  caught  within  the  sphincter,  it  may  give  rise  to  much  straining  and 
discomfort.  In  such  cases  there  may  be  frequent  desire  to  go  to  stool, 
without  the  ajopearance  of  a  dejection  ;  much  mucus  is  passed  from  the 
bowel,  and  the  fsecal  masses  may  be  grooved  from  the  pressure  of  the 
growth  during  their  passage.  If  the  disease  is  allowed  to  go  on  long  un- 
checked, the  child  becomes  pale  and  cachectic-looking  fi'om  constant  losa 
of  blood. 

Diagnosis. — The  special  form  of  haemorrhage  of  the  newly-born  (melaena 
neonatorum)  is  so  rare  a  complaint  that  in  every  case  where  blood  is 
ejected  from  the  mouth  or  passed  from  the  bowel  in  a  very  young  infant, 
we  should  rather  suspect  the  blood  to  be  furnished  from  some  extraneous 
source  ;  and  if  the  child  be  at  the  breast,  our  first  care  should  be  to  exam- 
ine the  nipple  of  the  mother  or  nurse  for  fissures  or  signs  of  erosion.  A 
true  haemorrhage  in  a  young  baby  is  at  once  indicated  by  pallor  of  the 
face,  sinking  of  the  fontanelle,  and  depression  of  temperature.  If,  after 
bringing  up  a  quantity  of  bright  blood,  the  chilcl  seem  contented  and 
happy,  without  loss  of  colour  or  any  sign  of  depression  or  distress,  it  i» 
unlikely  that  his  own  body  is  the  source  of  the  bleeding.  If,  on  the  con- 
trary, blanching  of  the  face,  coldness  of  the  extremities,  and  signs  of  gen- 
eral depression  accompany  or  precede  the  passage  of  blood,  there  can  be 
no  doubt  that  the  haemorrhage  is  no  misleading  phenomenon.  StUl,  it  is 
often  far  from  easy  to  ascertain  its  source.  If  the  bleeding  occur  at  only 
a  short  interval  after  birth,  and  succeed  to  a  prolonged  and  difficult  la- 
bour, or  arise  in  a  child  in  whom  the  respiratory  function  has  been  with 
difficulty  established,  we  may  suspect  the  phenomenon  to  be  symptomatic 
42 


658  DISEASE   IX   CHILDKEX. 

of  a  congested  state  of  the  Tiscera,  aided,  proLaljly,  by  a  special  liseraor- 
rhagic  tendency  in  the  child.  If  it  occur  some  days  later,  and  have  been 
preceded  by  signs  of  luieasiness  after  taking  the  breast,  some  difficulty  of 
deglutition  or  fi'equent  vomiting,  the  effusion  of  blood  is  jDOSsibly  due  to  a 
gastric  or  duodenal  ulcer  ;  but  a  positive  diagnosis  of  this  lesion  cannot 
be  ventured  upon.  If  haemorrhage  occur  solely  from  the  navel,  and  be 
accompanied  by  an  icteric  tint  of  skin,  the  case  is  probably  one  of  con- 
genital deficiency  of  the  bile-ducts.  If  previous  infants  in  the  same  family 
have  died  after  presenting  similar  symptoms,  the  probabihties  are  strong 
that  this  distressing  malformation  is  jjresent.  This  subject  is  considered 
elsewhere  (see  page  717). 

In  later  infancy  and  childhood  we  should  inquii-e  about  epistaxis,  and 
examine  the  throat  and  gums  for  ulceration  and  signs  of  recent  bleeding. 
If  the  apparent  hsematemesis  be  due  to  epistaxis,  blood  will  be  often  seen 
trickling  down  the  back  of  the  pharynx.  If  the  case  be  one  of  hsemor- 
rhagic  purpura,  we  notice  the  petechiEe  on  the  skin,  and  can  detect  the 
general  disjDOsition  to  ready  effusion  of  blood.  In  cases  of  hagmophUia 
the  same  tendency  is  probaljly  a  well-recognised  peculiarity  in  the  family, 
and  information  as  to  its  existence  is  usually  forthcoming.  In  the  mahg- 
nant  forms  of  the  specific  fevers  the  accompanpng  symptoms  are  usu- 
ally sufficiently  characteristic  of  the  nature  of  the  illness  ;  and,  more- 
over, the  existence  of  an  epidemic  in  the  neighbourhood  is  probably  weU 
known. 

In  cases  where  the  haemorrhage  is  due  to  a  local  cause,  the  source  of 
the  bleeding  may  be  discovered  from  the  symjDtoms  by  which  the  passage 
of  blood  has  been  attended.  Small  black  clots  lying  at  the  bottom  of  a 
thin,  dark-coloured  water  or  pea-soup-like  fluid,  usually  indicate  idceration 
of  the  bowek  Small  red  clots  or  streaks  are  commonly  dependent  upon 
catarrh  of  the  lower  part  of  the  colon,  with  tenesmus.  Eed  blood  in  larger 
quantity,  pure,  or  mixed  with  mucus,  and  j^assed  with  gi'eat  straining  and 
pain,  may  be  possibly  due  to  an  invagination  of  the  bowel,  or  may  be  the 
consequence  of  a  polypus  of  the  rectum.  In  cases  of  intussusception  other 
characteristic  symptoms  are  present.  If  the  blood  be  due  to  a  polypoid 
growth,  this  may  be  often  seen  at  the  end  of  defecation  caught  in  the  giip 
of  the  sphincter,  and  looking  like  a  bright  red  ball.  If  the  finger  is  in- 
troduced into  the  rectum,  the  poh-pus  can  be  distinctly  felt  attached  to 
the  posterior  wall  of  the  bowel  by  a  slender  stalk. 

Prognosis. — "When  hsemon-hage  occurs  in  the  new-born  infant,  the 
danger  is  always  great ;  but  the  probabilities  of  a  favoui-able  issue  depend 
partly  upon  the  degree  of  strength  of  the  child  himself,  and  partly  upon 
the  opinion  we  have  formed  as  to  the  source  of  the  bleeding.  A  well- 
nourished  infant  of  robust  constitution  can  often  bear  an  extraordinary 
loss  of  blood  without  sinking  under  the  haemorrhage.  A  weakly  infant 
succumbs  quickly.  If  we  have  reason  to  suspect  an  ulcer  of  the  stomach 
or  duodenum,  the  prognosis  is  exceedingly  unfavoui-able.  Also,  if  con- 
vulsions occur,  if  the  bleeding  continue  beyond  the  fii'st  twenty-foiu' 
houi's,  and  if  it  retiu'n  after  apparent  cessation,  we  have  reason  to  fear  the 
worst.  Of  Lederer's  eight  cases,  five  died.  Of  twenty-three  cases  collected 
by  Eilliet  and  Barthez,  eleven  ended  in  death.  Dr.  Groom  estimates  that, 
taking  all  forms  of  the  disease  together,  the  mortality  is  about  sixty  per  cent. 
In  older  children  the  danger  of  intestinal  haemorrhage  depends  upon  the 
cause  to  which  it  is  owing,  and  the  severity  of  the  condition  of  which  it 
is  the  consequence.  Eectal  polypi  are  readily  removed  ;  indeed,  some- 
times they  separate  spontaneously  and  are  discharged  mth  a  stool. 


GASTRO-IISrTESTIlSrAL   H^MOERHAGE — TREATMENT.  659 

Treatment. — In  cases  of  melsena  neonatorum,  the  child  must  be  fed 
•with  his  mother's  milk  given  with  a  spoon,  or  failing  this,  with  ass's  or 
goat's  milk,  diluted  with  an  equal  quantity  of  barley-water,  with  whey  and 
cream,  or  Avith  white  wine  whey.  Pancreatised  milk,  prepared  according 
to  the  directions  given  in  the  chapter  on  Infantile  Atrophy,  is  also  very- 
suitable.  Whatever  may  be  the  food,  it  should  be  given  cold  and  in  small 
quantities  at  a  time.  The  infant  must  be  kept  perfectly  quiet.  An  ice- 
bag  should  be  apphed  to  his  belly,  and  his  feet  must  be  kept  warm.  He 
may  take  internally  a  grain  of  gallic  acid,  or  a  couple  of  grains  of  the  ex- 
tract of  krameria,  every  two  or  three  hours ;  or  one  or  two  drops  of  oil 
of  turjDentine  may  be  given  every  hour.  In  addition,  foui-  or  five  ounces  of 
the  infusion  of  krameria  may  be  thrown  up  the  bowel.  The  strength  of 
the  child  must  be  supported  by  white  wine  whey,  or  by  a  few  drops  of 
brandy  given  at  short  intervals. 

In  older  children  haemorrhage  must  be  treated  according  to  the  condi- 
tion which  has  given  rise  to  it.  Polypus  of  the  rectum  is  removed  by 
seizing  the  growth  with  a  forceps  and  passing  a  silk  ligature  tightly  round 
the  pedicle.  But  in  early  life  the  slender  stalk  often  snaps  when  stretched, 
and  the  mere  action  of  drawing  the  polypus  below  the  sphincter  often 
detaches' it  from  the  mucous  membrane.  Its  separation  is  followed  by  no 
bleeding,  and  hsemorrhage  ceases  from  that  time. 


CHAPTEE  IX. 

ULCERATION  OF  THE  BOWELS. 

The  subject  of  ulceration  of  the  intestinal  mucous  membrane  must,  neces- 
sarily, be  referred  to  in  describing  the  various  diseases  in  the  course  of 
which  such  ulcerations  are  Hable  to  arise.  Still,  it  seems  desirable,  in  ad- 
dition, to  devote  a  special  chapter  to  its  consideration.  It  is  not  uncom- 
mon to  meet  with  ulceration  of  the  bowels  in  children  who  have  not  re- 
cently suffered  from  acute  disease,  and  in  whom  no  special  cause  for  the 
intestinal  lesion  can  be  discovered.  Such  latent  cases  are  not  always  easy 
of  diagnosis,  for  ulceration  of  the  bowels  is  not  necessarily  attended  vdth 
diarrhoea.  Purging,  when  it  occurs,  is  dependent  not  upon  the  ulcerative 
process,  but  upon  the  intestinal  catarrh  which  accompanies  the  breach  of 
surface.  When  the  catarrh  is  at  an  end  the  purging  ceases,  although  the 
ulcers  may  be  still  unhealed.  Typhoid  fever  in  early  life  often  runs  its 
whole  course  without  any  looseness  of  the  bowels,  and  this  in  instances 
where,  from  the  length  and  severity  of  the  attack,  there  can  be  little  doubt 
that  ulceration  has  been  present.  So,  also,  in  cases  of  scrofulous  or  tuber- 
cular ulceration  of  the  intestinal  mucous  membrane,  the  occasional  attacks 
of  purging  are  often  separated  by  considerable  intervals  during  which  the 
bowels  are  sluggish,  although,  on  post-mortem  examination  of  the  body, 
extensive  breaches  of  surface  are  discovered  in  the  intestinal  tract. 

Ulceration  of  the  bowels  may  be  acute  or  chronic.  The  acute  form 
is  seen  in  cases  of  typhoid  fever,  dysentery,  and  inflammatory  conditions  of 
the  bowel  which  give  rise  to  lesions  of  the  mucous  membrane,  either  by 
the  separation  of  superficial  sloughs  or  by  ulcerative  inflammation  of  the 
glandular  follicles.  If  life  be  prolonged  the  ulcerative  process  may  pass, 
in  certain  cases,  into  a  chronic  stage,  and  lead  to  serious  interference  with 
the  nutrition  of  the  patient.  The  chronic  form  of  the  lesion  will  alone  be 
considered  in  the  present  chapter.  It  occurs  in  two  principal  varieties  in 
the  child,  viz. :  the  simple  ulceration  from  prolonged  intestinal  catarrh,  and 
the  scrofulous  or  tubercular  ulceration,  which  so  often  accompanies  a  sim- 
ilar condition  of  the  lungs. 

Morbid  Anatomy. — Simple  ulceration  of  the  bowels  is  seen  principally 
in  infants  and  the  younger  children.  The  part  of  the  bowel  aflfected  is  the 
large  intestine  and  lower  part  of  the  ilium.  The  ulcers  are  very  shallow, 
and  can  best  be  detected  by  inspecting  them  sideways.  They  may  be  seat- 
ed on  the  summit  of  the  longitudinal  folds  of  mucous  membrane,  and  are 
then  elongated  or  sinuous.  Others  are  seen  between  the  folds,  and  are 
small  circular  breaches  of  the  surface,  which  can  often  only  be  detected  by 
careful  scrutiny,  as  their  bases  are  of  the  same  tint  as  that  of  the  mucous 
membrane  surrounding  them.  The  process  by  which  they  are  formed 
appears  to  be  as  follows : — The  follicles  become  enlarged  and  elevated 
above  the  surface  like  little  pearly  beads.  Their  contents  then  become 
purulent,  and  the  follicles  still  further  increase  in  size.     Lastly,  the  roof  of 


ULCERATIOlSr   OF   THE    BOWELS — SYMPTOMS.  661 

the  follicle  is  detached  and  the  contents  escape,  leaving  a  clean-cut  ulcer. 
Mixed  up  with  the  ulcers  are  other  foUicles — large,  elevated,  and  semi- 
transparent — the  contents  of  which  have  not  yet  become  purulent.  The 
ulcers  are  roundish  or  irregular  in  shape,  and  vary  considerably  in  size. 
Their  edges  are  well  defined  and  congested,  their  floor  uneven,  and  of  a 
reddish  or  grayish  colour. 

Tubercular  or  scrofulous  ulceration  of  the  bowels  is  more  common  in 
children  of  three  or  four  years  old  and  upwards  than  in  infants.  This 
form  of  lesion  is  usually  associated  with  scrofulous  or  tubercular 'disease 
of  the  lung,  and  almost  invariably  with  caseous  enlargement  of  the  mesen- 
teric glands.  The  ulceration  appears  to  be  chiefly  of  a  scrofulous  nature, 
the  presence  of  the  gray  granulations  being  only  an  occasional  and  second- 
ary consequence  of  the  caseous  degeneration  of  the  follicular  structures. 
The  seat  of  the  disease  is  usually  the  ilium,  and  the  glands  affected  are  the 
follicles  of  Peyer's  patches  and  the  solitary  glands,  especially  those  in  the 
neighbourhood  of  the  ilio-caecal  valve.  Primarily,  the  destructive  changes 
are  limited  to  these  parts.  Thus,  the  follicles  swell  up  from  great  multi- 
plication of  their  corpuscular  elements.  They  then  undergo  cheesy  de- 
generation, soften,  and  form  a  number  of  closely-set  ulcers,  which  unite  at 
their  borders  and  give  rise  to  more  or  less  extensive  areas  of  ulceration. 
Their  edges  are  soft,  red,  and  uneven,  and  their  floor  red  or  grayish  in 
colour.  The  ulcerative  process  does  npt  confine  itself  to  the  area  of  Pey- 
er's patches,  but  extends  laterally  along  the  course  of  the  smaller  arteries 
■and  veins  by  a  similar  process  of  caseation  and  softening,  so  as  often  to 
encircle  the  gut  completely.  The  infilti-ation  advances  into  the  neighbour- 
ing tissues,  and  causes  gradual  disintegration  and  destruction.  At  the 
same  time  the  ulcer  deepens,  but  seldom  passes  beyond  the  muscular  coat. 
As  a  secondary  process  gray  granulations  may  appear,  and  miliary  nodules 
are  then  seen  in  the  tunica  adventitia  of  the  smaller  vessels,  especially  the 
arteries  and  lymphatics.  The  serous  surface  at  the  site  of  the  ulcer  is 
opaque  and  reddened,  and  may  also  contain  gray  granulations.  Some- 
times adhesive  peritonitis  is  set  up,  and  neighbouring  portions  of  intestine 
become  glued  firmly  together.  If  in  these  cases  rupture  of  the  floor  of  the 
ulcer  take  place,  the  intestinal  contents  are  extravasated,  not  into  the  gen- 
-eral  peritoneal  cavity,  but  into  a  limited  pouch  formed  by  the  adherent 
bowels. 

The  simple  form  of  ulcer  may  cicatrise  and  leave  little  trace  ;  but  this 
termination  is  less  common  in  the  more  severe  form  which  is  due  to  a 
tubercular  or  scrofulous  cachexia.  Still,  even  in  these  cases  cicatrisation 
may  take  place  here  and  there,  and  on  account  of  the  transverse  extension 
of  the  breach  of  surface,  may  lead  to  serious  contraction  of  the  channel  of 
the  gut. 

Symptoms. — Ulceration  of  the  bowels  may  be  attended  by  few  symp- 
toms, and  if,  as  sometimes  happens,  diarrhcea  is  absent,  the  nature  of  the 
illness  may  be  completely  overlooked.  As  a  rule,  the  special  symptoms  of 
the  intestinal  lesion  have  been  preceded  by  a  prolonged  attack  of  purging, 
which  has  caused  serious  interference  with  nutrition,  and  greatly  reduced 
the  general  strength.  Abdominal  pain  is  not  necessarily  present,  but 
often  attacks  of  pain  of  a  colicky  character  are  complained  of,  and  these 
are  usually  found  to  precede  the  passage  of  a  stool.  There  may  be  no  ob- 
vious tenderness  on  pressure  of  the  abdominal  wall,  but,  in  many  instances, 
deep  pressure  in  the  course  of  the  colon  seems  to  give  rise  to  uneasiness. 
Still,  even  in  cases  where  tenderness  appears  to  be  comjoletely  absent, 
some  tension  of  the  abdominal  parietes  will  be  noticed.     Indeed,  this 


662  DISEASE  IlSr   CHILDRElSr, 

symptom  is  nearly  always  present,  and  careful  palpation  of  the  abdomen 
■will  rarely  fail  to  detect  it.  Tlie  tension  is  not  necessarily  general.  Often 
it  is  limited  to  the  'side  upon  wLicli  the  ulceration  exists,  as  if  the  muscular 
parietes  contracted  instinctively  to  protect  the  sensitive  part  from  injury. 
The  belly  is  usually  more  or  less  distended  from  flatulent  accumulation, 
but  this  "symptom  varies  in  degree.  Still,  although  fuller  than  natural,  it 
appears  normal  to  the  eye  ;  and  there  is  no  loss  of  the  natural  markings 
such  as  is  seen  in  cases  of  peritonitis.  If  the  mesenteric  glands  are  en- 
larged they  may  be  often  felt  on  deep  pressure,  and  the  supei-ficial  veins 
of  the  abdomen  are  then  unnatm-ally  visible. 

The  appearance  of  the  stools  is  very  characteristic.  The  bowels  may 
not  be  relieved  many  times  in  the  day.  Sometimes  they  are  even  costive. 
In  the  latter  case  the  stools  vary  in  character.  They  may  consist  for  the 
most  part  of  light-colom-ed  lumps,  often  covered  with  mucus,  and  some- 
times showing  a  streak  of  blood.  But  every  now  and  again  a  loose  motion 
will  be  passed  which  at  once  discloses  the  nature  of  the  case.  The  mo- 
tions which  are  characteristic  of  the  lesion  are  of  two  kinds.  The  first 
consists  of  a  dark  reddish-brown  water,  intensely  offensive  and  putrid- 
smelHng.  It  deposits  a  sediment  of  shreddy,  flaky  matter,  often  contain- 
ing little  black  spots  which  are  minute  clots  of  blood,  and  sometimes  smaU, 
pale,  hard  fsecal  lamps.  The  second  is  a  pale  yeUow  homogeneous  fluid 
of  the  consistence  of  cream  or  thin  paste.  It  often  has  a  cui'ious  mucila- 
ginous appearance  as  the  vessel  containing  it  is  tilted  fi'om  side  to  side. 
This  form  of  stool  has,  like  the  first,  an  offensive  smeU,  but  not,  like  it,  an 
odour  of  putrefaction. 

Haemorrhage  from  the  bowels  is  seldom  copious.  Usually  it  occurs  as 
black  clots,  hke  Uttle  particles  of  soot ;  but  sometimes  larger  black  lumps 
may  be  seen.  If  there  be  an  ulcer  at  the  lower  part  of  the  rectum  the 
blood  is  redder  in  colour,  and  may  be  in  larger  quantity.  The  number  of 
the  stools  varies  from  one  or  two  to  twent}-,  or  even  more,  in  the  twenty- 
foui-  houi'S.  Their  passage  is  sometimes  preceded  by  shght  cohcky  pain  ; 
and  if  the  lower  part  of  the  rectum  is  the  seat  of  ulceration,  there  may  be 
some  straining  at  stool,  and  the  bowel  may  prolapse.  It  is  not  common 
for  an  ulcer  to  occupy  this  part  of  the  rectum  ;  but  should  it  do  so,  some 
serious  consequences  have  been  noted.  The  irritation  excited  by  the  le- 
sion just  within  the  internal  sphincter  may  cause  spasmodic  closru-e  of  the 
lower  outlet,  so  that  much  difficulty  is  met  with  in  evacuating  the  bowels. 
As  a  result  of  this  obstruction,  great  enlargement  and  hypertrophy  of  the 
rectum  may  occur,  and  we  find  tympanitic  distention  of  the  belly,  and 
many  of  the  sjTnptoms  of  imj)action  of  fseces. 

A  child  who  is  the  subject  of  intestinal  ulceration  is  not  necessarily 
very  thin.  The  degree  to  which  nutrition  is  interfered  with  depends 
upon  the  amount  of  intestinal  catarrh  and  consequent  diarrhoea.  If  the 
pui'ging  is  severe,  wasting  is  rapid ;  but  if  the  bowels  are  not  much  re- 
laxed, nutrition  may  go  on  well,  and  the  child  progressively  increase  in 
weight,  although  the  character  of  the  stools  indicates  that  the  ulcers  are 
still  unhealed.  The  appetite  is  often  good,  and  the  tongue  clean  ;  and  ex- 
cept for  a  certain  pinched  look  of  the  face  and  distress  in  the  expression 
of  the  child,  he  might  be  thought  to  be  suffeiing  from  a  very  trifling  com- 
plaint. Even  in  cases  where  the  ulceration  is  of  a  scrofulous  nature  the 
same  rule  holds  good,  provided  the  lungs  are  healthy.  Caseous  enlarge- 
ment of  the  mesenteric  glands  does  not  necessarily  produce  wasting  ;  and 
if  the  ulceration  is  not  extensive,  the  temperatru-e  high,  or  the  pui'ging  se- 
vere, the  lesion  may  produce  no  noticeable  impaii-meut  of  the  child's  nu- 


ULCEEATIOK   OF   THE   BOWELS — SYMPTOMS.  663 

trition.  The  heat  of  the  body  is  not  always  increased.  I  have  known 
cases  where  characteristic  stools,  containing  shreddy  matter  and  blood- 
clots,  continued  to  be  passed  for  months,  and  where  caseous  glands  could 
be  distinctly  felt  in  the  abdomen  on  deep  pressure,  run  their  whole  course 
and  end  in  recovery,  with  a  temperatm-e  which  seldom  rose  above  99°. 

Ulceration  of  the  bowels  is  sometimes  complicated  with  peritonitis.  In 
cases  of  scrofulous  or  tubercular  ulceration  of  the  bowels,  tubercular  peri- 
tonitis is  a  common  secondary  lesion.  But  a  simple  ulceration  may  also 
be  accompanied  by  inflammation  of  the  serous  lining  of  the  abdomen 
without  perforation  of  the  bowels  having  taken  place. 

A  boy,  aged  six  years,  was  struck  on  the  abdomen  with  a  heavy  piece  of 
wood.  The  accident  made  him  feel  faint,  and  he  vomited  several  times  on 
that  and  the  following  days.  On  the  day  after  the  injury  he  complained 
much  of  pain  in  the  belly,  and  from  that  time  suffered  from  frequent  col- 
icky pains  in  the  abdomen,  and  diarrhoea,  which  often  obliged  him  to  keep 
his  bed.  He  was  admitted  into  the  East  London  Children's  Hospital  six 
months  after  the  accident.  At  this  time  the  boy  was  pale,  but  not  very 
thin  (he  weighed  thu'ty-two  pounds  twelve  ounces).  He  complained  of 
pain  in  the  right  side  of  the  belly  and  over  the  epigastrium,  and  there  was 
considerable  tension  of  the  parietes  in  these  situations.  The  abdomen 
was  rather  distended,  but  was  not  tender.  There  was  no  fluctuation  or 
dulness  in  the  flanks,  but  much  gui-gling  could  be  felt  and  heard  on  palpa- 
tion. His  tongue  was  furred  in  two  lateral  bands.  The  bowels  acted  four 
times  in  the  day,  the  stools  being  pale,  small,  and  solid.  The  boy  had  a 
pinched,  distressed  expression,  and  seemed  languid  and  dull,  but  expressed 
himself  as  quite  comfortable  except  for  the  occasional  pains  in  the  belly. 
There  was  no  albumen  in  his  urine.  The  lungs  and  heart  were  healthy. 
His  temperature  at  6  p.m.  was  99.4°. 

A  few  days  after  the  lad's  admission  his  temperature  rose  ;  he  began  to 
vomit,  and  the  bowels  became  much  relaxed.  The  stools  consisted  of  dark 
brown  liquid,  or  of  fluid  like  pea-soup,  with  small  hard  faecal  masses.  The 
vomiting  continued,  and  the  belly  became  swollen,  tympanitic,  and  very 
tender.  The  child  then  rapidly  wasted  and  became  exceedingly  prostrate. 
Delirium  came  on,  and  he  sank  at  the  end  of  a  fortnight.  During  the  last 
week  his  temperature  varied  between  99°  and  102°. 

On  examination  of  the  body  there  were  signs  of  old  peritonitis,  due 
probably  to  the  accident.  In  addition,  much  recent  lymph  was  found  coat- 
ing the  intestines.  In  the  ihum  several  of  Peyer's  patches  were  found  to 
be  the  seat  of  ulceration.  The  ulcers  were  shallow,  with  a  grayish,  uneven 
floor  and  thickened  edges.     There  were  no  gray  granulations  anywhere. 

This  boy's  condition  when  he  entered  the  hospital  illustrates  very  well 
the  symptoms  often  found  in  cases  of  ulceration  of  the  bowels,  for  there  is 
no  reason  to  suppose  that  he  was  then  suffering  from  peritonitis.  Abdom- 
inal pain  of  a  colicky  character  gomg  on  for  months,  especially  if  combined 
with  tension  of  the  parietes,  and  a  history  of  more  or  less  persistent  diar- 
rhoea, is  suggestive  of  intestinal  ulcer,  and  the  pinched,  distressed  look  of 
the  boy's  face  quite  excluded  the  idea  that  these  symptoms  were  due  to 
any  unimportant  derangement,  however  persistent.  It  is  an  invariable  rule, 
which  shovdd  never  be  forgotten  in  clinical  investigation,  that  in  a  child  a 
haggard  face  means  serious  illness.  However  insignificant  the  symptoms 
and  signs  may.  appear,  if  a  child  look  ill  the  case  is  not  one  to  be  neglected 
or  lightly  regarded.  The  intestinal  lesion  in  this  boy  was  probably  the 
consequence  of  a  chronic  catarrh  of  the  bowels  of  many  months'  standing  ; 
for  from  the  time  of  the  accident  he  continued  to  suffer  from  persistent 


664  DISEASE  ITT   CHILDRETT. 

loosGBess  of  the  bowels,  with  attacks  of  colicky  pain.  The  return  of  the  ca- 
tarrh followed  upon  the  action  of  an  aperient  which  reheved  his  bowels  of 
a  large  quantity  of  hard  fsecal  masses,  and  the  irritation  thus  excited  no 
doubt  induced  the  second  attack  of  peritonitis  from  which  he  died. 

If  there  is  any  reason  to  suspect  ulceration  of  the  mucous  membrane 
of  the  bowels,  aperients  are  not  to  be  recommended.  Our  whole  efforts 
should  be  directed  to  promote  the  healing  of  the  ulcers  by  quieting  peris- 
taltic movement.  Therefore,  however  important  it  may  seem  to  remove 
fjecal  accumulation,  we  must  remember  that  an  aperient  only  sets  up  fresh 
irritation,  and  that  its  action  may  be  followed  by  very  serious  consequences. 

As  a  rule,  the  lower  down  in  the  colon  the  ulceration  is  seated,  the 
more  numerous  are  the  evacuations  and  the  more  distressing  the  tenesmus 
and  the  pain.  Still,  even  if  an  ulcer  occupy  the  sigmoid  flexure  or  rectum, 
there  is  not  always  diarrhoea  ;  indeed,  sometimes  the  fsecal  matter  presents 
itself  only  in  the  form  of  hard  scybala  mixed  with  very  offensive  muco- 
purulent fluid.  In  these  cases,  if  haemorrhage  occur,  it  is  usually  more 
copious,  and  the  blood  more  natural  in  colour,  than  when  the  ulcers  occupy 
any  other  j)ortion  of  the  bowel.  Constipation  is  most  liable  to  be  formd  in 
cases  where  the  lesion  is  seated  in  the  small  intestine,  the  colon  being 
healthy  ;  but  even  in  this  form  of  the  disease,  any  additional  irritation 
which  sets  up  catarrh  and  increases  the  peristalsis  of  the  larger  gut  may 
give  rise  to  diarrhoea.  An  ulcer  of  the  duodenum  would  probably  excite 
distressing  vomiting  and  pain  at  an  intei-val  after  food.  Such  a  lesion  in 
the  child  has  never  come  under  my  notice. 

Diagnosis. — If  the  symptoms  of  ulceration  are  well  marked,  there  is 
little  difficulty  in  ascribing  them  to  their  true  cause.  An  abdomen  full, 
Avithout  great  distention  or  loss  of  the  natural  sui-face  markings  ;  increased 
tension  of  the  parietes,  with  tenderness  on  deep  pressure  ;  diarrhoea,  with 
colicky  pain,  the  stools  consisting  of  dark,  putrid-smelHng,  watery  fluid,  de- 
positing brown  or  yellow  shreddy  matter  and  small  black  blood-clots— this 
group  of  symptoms,  when  combined  with  a  distressed  expression  of  face, 
is  very  characteristic  of  intestinal  ulceration.  The  chief  difficulty  in  such 
a  case  would  be  to  exclude  tubercular  peritonitis  ;  for  this  additional  lesion 
might  be  present  without  excessive  tenderness,  without  fluctviation,  and 
without  any  caseous  lumps  being  detected  on  palpation.  The  belly,  how- 
ever, would  be  more  distended  and  globular  ;  the  natm-al  markings  of  the 
surface  would  be  absent ;  the  temperature  would  probably  be  decidedly 
febrile  ;  and  in  most  cases,  if  the  child  were  laid  on  his  side  so  as  to  allow 
of  the  fluid  accumulating  in  one  flank,  some  evidence  of  its  existence  would 
be  perceived  on  turning  him  rapidly  on  to  his  back  and  immediately  pal- 
pating or  percussing  the  part  which  had  been  dependent.  It  is,  however, 
fortunately,  uncommon  to  find  cases  of  chronic  tubercular  peritonitis  in 
which  the  symptoms  are  so  obscure.  Usually  semi-fluctuation  is  readily 
discovered,  and  caseous  masses,  or  unequal  resistence  of  the  abdominal  con- 
tents, can  be  noticed  on  examination. 

If  the  ulceration  be  accompanied  by  constipation  or  solid  stools,  the 
case  may  be  mistaken  for  one  of  fsecal  accumulation.  The  colicky  pains 
and  small  lumpy  evacuations  are  very  suggestive  of  this  condition,  and 
even  if  the  stools  are  occasionally  loose,  the  symptom  is  not  unkno"^Ti  in 
cases  of  impacted  rectum.  A  httle  reflection  will,  however,  convince  us 
that  there  is  more  in  the  case  than  a  loaded  bowel  is  capable  of  explaining. 
We  find  in  most  instances  a  history  of  previous  continued  diarrhoea  ;  if 
tenderness  be  absent,  there  is  still  some  tension  of  the  abdominal  wall ; 
and  the  distressed  expression  of  the  child's  face  assui-es  us  of  the  existence 


ULCEEATION   OF   THE   BOWELS — PROGZSTOSIS.  665 

of  serious  disease.  Moreover,  au  examination  ^^er  anum  detects  no  accumu- 
lation in  the  rectum,  and  a  copious  enema,  althougli  it  may  remove  solid 
f  iGcal  lum^DS,  in  no  way  improves  the  condition  of  the  patient. 

If  we  are  satisfied  as  to  the  presence  of  the  ulceration,  we  have  still  to 
decide  whether  the  lesion  is  of  a  simple  character,  or  is  the  consequence  of 
a  scrofulous  or  tubercular  cachexia.  The  older  the  child,  the  greater  the 
likelihood  that  the  ulceration  is  not  simj)ly  catarrhal.  After  the  age  of 
three  years,  the  manifestations  of  the  scrofulous  diathesis  become  common  ; 
and  at  this  age,  chronic  catarrh  of  the  bowels  seldom  runs  a  sufficiently 
persistent  course  to  set  up  ulceration  unless  aided  by  some  Aice  of  the 
constitution.  If,  however,  the  child  have  scrofulous  or  tubercular  tenden- 
cies, a  much  less  prolonged  irritation  of  the  mucous  membrane  will  give 
rise  to  caseation  and  softening  in  the  glandular  follicles.  The  presence  of 
enlarged  mesenteric  glands,  chronic  lung  disease,  or  other  sign  of  the 
scrofulous  constitution,  allows  us  to  infer  that  the  intestinal  lesion  is  of  a 
similar  pathological  character.  The  temperature  is  not  greatly  to  be  relied 
upon  in  these  cases ;  for  it  is  not  necessarily  elevated  in  cases  of  scrofulous 
ulceration,  while  it  may  be  raised  from  accidental  causes  in  the  simple  form 
of  the  lesion.  Nor  is  the  state  of  nutrition  of  much  value  as  a  guide  ;  for 
this  depends  less  upon  the  nature  of  the  ulcer  than  upon  the  degree  to 
wlaich  catarrh  of  the  bowels  may  have  reduced  the  strength,  and  interfered 
mth  the  digestion  and  absorption  of  food.  If  the  child  show  no  sign  of 
the  scrofulous  cachexia,  if  his  lungs  appear  to  be  healthy,  and  if  tubercu- 
lar peritonitis  can  be  excluded,  we  may  infer  the  ulceration  to  be  of  a  sim- 
ple character,  although  his  general  strength  be  poor,  and  his  nutrition  un- 
mistakably impaired. 

If  the  ulceration  be  tubercular  from  a  secondaiy  formation  of  the  gray 
granulation  around  the  ulcer,  and  in  other  parts,  nutrition  is  at  once  pro- 
foundly affected,  and  wasting  goes  on  with  rapidity.  In  such  a  case,  all  the 
symptoms  of  general  tuberculosis  are  present,  and  the  child  often  dies  from 
tubercular  meningitis.  Still,  it  must  be  confessed  that  cases  sometimes 
present  themselves  in  which  aU  the  symptoms  of  acute  tuberculosis  are 
noticed  without  a  single  gray  granulation  being  discovered  in  the  body 
after  death.  The  case  may  even  terminate  with  head  symptoms  indistin- 
guishable from  those  of  tubercular  meningitis,  although  the  interior  of  the 
cranium  appears  to  be  healthy,  and  the  most  thorough  search  discovers  no 
gray  tubercle  in  the  meninges  of  the  brain.  It  is  difficult  to  explain  these 
cases.     Fortunately,  they  are  very  exceptional. ' 

Prognosis. — In  a  case  of  simple  ulceration  from  prolonged  intestinal 
catarrh,  recovery  will  often  take  place  under  judicious  treatment  if  there  be 
no  comjDlication,  and  if  oedema  have  not  occurred.  The  latter  symptom, 
although  it  is  far  from  indicating  that  the  patient  wiU  certainly  die,  is  yet 
of  unfavoiu'able  import,  as  it  shows  a  state  of  great  weakness,  and  weakness 
in  itself  renders  a  child  less  responsive  to  the  action  of  remedies. 

If  the  ulceration  be  scrofulous,  the  prognosis  is  still  less  favourable  ;  but 
here,  if  the  strength  is  not  greatly  reduced,  and  if  other  organs  are  healthy, 
recovery  may  take  place.  Caseous  enlargement  of  the  mesenteric  glands 
does  not  appear  to  add  to  the  danger  of  the  case  ;  but  if  serious  lung  mis- 
chief is  present,  the  conciu'rence  of  the  two  lesions  leaves  us  little  room  for 
hope.  If  secondary  tuberculosis  occur,  with  formation  of  the  gray  granu- 
lation in  the  neighbourhood  of  the  ulcer  and  elsewhere,  death  is  certain. 

'  A  case  presenting  tliese  deceptive  phenomena  occurred  some  time  ago  in  the  Vic- 
toria Park  Hospital,  and  was  published  by  Dr.  S.  West,  in  the  Lancet  for  September 
30,  1882. 


666  DISEASE   IIN"   CHILDEEJSr. 

Ti^eatment. — The  utmost  care  is  required  in  the  treatment  of  these 
cases  if  the  illness  is  to  be  conducted  to  a  favoui'able  issue.  Our  endeavours 
must  be  directed  to  quiet  irritation  ;  to  prevent  the  occurrence  of  fresh 
catarrh  ;  to  reduce  peristaltic  action,  so  that  the  healing  of  the  ulcers  may 
not  be  interfered  with  ;  to  support  the  strength  of  the  patient,  and  to  fur- 
ther cicatrisation  by  suitable  medication. 

The  child  should  be  kept  in  bed  in  a  vs^ell-ventilated  room,  and  his 
belly  should  be  protected  by  a  broad  layer  of  cotton-wool  confined  by 
a  suitable  bandage.  All  discharges  and  soiled  linen  should  be  at  once 
removed,  and  every  means  be  employed  to  keep  the  air  of  the  room  fresh 
and  pure.  The  diet  must  be  regulated  so  as  to  convey  nourishment  with- 
out supjolying  material  for  fermentation.  As  long  as  catarrh  persists,  fer- 
mentable food  is  to  be  avoided  ;  and  even  when  the  diarrhoea  has  been 
arrested,  the  capacity  for  digesting  such  a  diet  still  continues  small.  Milk 
must  be  positively  forbidden ;  and  starchy  matters  can  only  be  taken,  if 
at  all,  in  very  small  quantity.  An  infant  must  be  fed  Avith  weak  veal  or 
chicken-broth  and  barley-water  in  equal  proportions  ;  whey,  plain,  or  if 
the  child  be  feeble,  made  with  sherry  (white  wine  whey),  and  cream  ;  yolk 
of  egg  beaten  up  with  whey  or  veal-broth  ;  and  MeUiu's  food  dissolved  in 
either  broth  or  whey,  and  mixed  with  barley-water.  The  meals  must  be 
small  and  frequent ;  and  it  is  advisable  to  make  constant  changes,  so  as  to 
furnish  a  sufficient  variety.  If  the  purging  be  severe,  no  more  than  one 
tablespoonful,  or  even  less,  can  be  given  at  one  meal  ;  and  all  food  must  be 
given  cold. 

After  the  age  of  eighteen  months,  raw  mutton  or  beef  forms  a  very  val- 
uable remedy.  This  should  be  prepared  as  directed  in  the  treatment  of 
chronic  diarrhoea,  and  may  be  eaten  plain  or  diffused  thi'ough  broth  or 
jelly.  Uncooked  meat  so  prepared  is  very  nutritious  and  digestible  ;  and 
even  if  not  completely  digested,  the  residue  appears  to  be  perfectly  unu-ri- 
tating  to  the  bowels.  Still,  it  is  well  immediately  before  the  meal  to  give 
a  dose  of  pepsin  (gr.  iij.-v.)  dissolved  in  a  few  ch-oiDS  of  dilute  hydrochloric 
acid,  in  order  to  aid  the  process  of  digestion.  If  the  child  be  between  the 
ages  of  one  and  a  half  and  two  years,  and  the  purging  be  severe,  little 
other  food  besides  the  raw  meat,  meat-jelly,  and  broth  should  be  allowed 
for  a  few  days,  until  the  violence  of  the  catarrh  is  reduced.  Afterwards, 
or  in  older  children  at  first,  yolk  of  egg,  well-boiled  cauliflower  or  Spanish 
onion  pressed  through  a  fine  sieve,  and  thin  well-toasted  bread  may  be  al- 
lowed. In  some  of  these  cases,  where  the  power  of  digesting  starch  seems 
reduced  to  a  minimum,  a  good  substitute  for  bread  is  the  malted  child's 
biscuit  made  by  Messrs.  Hill  &  Sons  of  Bishopsgate  Street.  If  these 
are  objected  to,  a  loaf  may  be  baked  expressly  for  the  child  in  which  a  pro- 
portion of  finely-ground  fresh  malt  is  introduced — one  part  of  malt  to  two 
parts  of  flour.  It  is  well,  also,  in  addition,  to  give  a  spoonful  of  Hoff's  ex- 
tract of  malt  directly  after  the  meal.  AVhen  the  intestinal  catarrh  has 
been  arrested,  milk  may  be  returned  to,  but  should  be  given  cautiously. 
In  most  cases,  it  is  the  curd  of  the  milk  which  is  digested  with  such  diffi- 
culty ;  and  I  have  found  the  pancreatised  milk  prepared  with  Benger's 
pancreatic  solution,  as  directed  elsewhere  (see  page  606),  to  be  weU  borne 
when  ordinary  milk  could  not  be  taken.  In  other  cases,  skimmed  milk 
seems  to  agree  better  than  milk  from  which  the  cream  has  not  been  re- 
moved. Whatever  be  the  age  of  the  child,  so  long  as  he  is  taking  milk  a 
careful  watch  must  be  kept  upon  the  digestive  process  ;  and  any  sign  of 
flatulence  or  acidity,  and  especially  any  return  of  the  purging,  should  be  a 
signal. for  reducing  the  quantity  of  the  milk,  or  even  for  omitting  it  for  a 


ULCEEATIOlSr   OF   THE   BOWELS — TREATMENT.  667 

time  altogether  from  the  diet.  If  the  child  is  weakly,  or  appears  to  be  ex- 
hausted by  the  purging,  stimulants  must  be  given  as  required.  White 
wine  whey  for  infants,  and  brandy-and-egg  mixture  for  children  of  all  ages, 
are  the  most  valuable. 

With  regard  to  medicines  : — As  long  as  there  is  jDurging,  astringents 
with  opium  are  indicated.  It  is  well  in  these  cases  not  to  rely  too  much 
upon  one  form  of  remedy,  for  we  shall  often  be  forced  to  make  frequent 
changes  in  the  prescription  in  order  to  guide  the  disease  to  a  favourable 
ending.  If  the  stools  consist  of  the  homogeneous,  pasty  liquid  matter 
which  has  been  described,  nitrate  of  silver  is  pre-eminently  useful.  One- 
eighth  to  one-fifth  of  a  grain  should  be  combined  with  a  few  drops  of  di- 
lute nitric  acid,  and  one  or  two  drops  of  laudanum,  in  water  sweetened 
with  glycerine.  This  dose  can  be  given  three  times  a  day.  If  from  tenes- 
mus, pain  in  the  right  iliac  fossa,  or  the  apjoearance  of  bright  blood  in  the 
stools,  there  is  reason  to  believe  the  large  bowel  to  be  the  seat  of  the  le- 
sion, internal  administration  of  the  drug  may  be  supplemented  by  the  use 
of  the  salt  locally.  For  a  child  two  years  of  age,  the  lower  bowel  should 
be  first  cleared  out  by  a  copious  injection  of  tejpid  water,  and  afterwards 
two  grains  of  the  nitrate  dissolved  in  four  ounces  of  water  must  be  thrown 
up  the  bowel  through  a  long  tube.  If  tenesmus  is  urgent,  five  drops  of 
laudanum  may  be  added  to  the  medicated  injection  ;  or,  after  the  return 
of  the  nitrate,  the  laudanum,  mixed  with  half  an  ounce  of  thin  warm  starch, 
may  be  thrown  into  the  bowel.  The  astringent  injection  can  be  repeated  for 
three  or  four  nights  in  succession,  and  can  then  be  given  only  on  alternate 
nights,  if  the  symptoms  still  jDersist.  Instead  of  the  silver  salt,  sulphate  of 
copjDer  (half  a  grain  to  the  ounce  of  water)  may  be  used  for  the  injection,  and 
is  often  of  service.  This  treatment  by  injections  is  useful  not  only  by  ap- 
plying the  astringent  directly  to  the  affected  part,  but  also  by  clearing  away 
hardened  lumps  of  fsecal  matter,  which  are  very  apt  to  be  retained  and  keep 
up  irrita,tion  even  when  the  stools  generally  are  loose  and  frequent. 

Another  useful  remedy  is  the  extract  of  hsematoxylon.  Three  to  five 
grains  may  be  combined  with  one  or  two  drops  of  laudanum,  and  two  to 
four  drops  of  ipecacuanha  wine  in  the  compound  chalk  mixture,  and  given 
three  times  in  the  day.  A  combination  of  the  extracts  of  hsematoxylon 
and  rhatany  (gr.  iij.  of  each)  is  often  found  of  signal  efficacy  if  the  pvirging* 
is  obstinate  ;  or  gallic  acid  (gr.  ij.-v.),  with  a  few  drops  of  aromatic  sul- 
phuric acid,  may  be  used.  Opium  should  be  ahvays  added  to  the  astrin- 
gent, whatever  this  may  be,  in  order  to  reduce  irritability  of  the  mucous 
membrane,  and  quiet  peristaltic  movement.  Sometimes  we  find  cases, 
which  have  resisted  aU  other  treatment,  yield  to  bismuth  given  in  large 
doses.  For  a  child  of  two  years  old,  fifteen  grains  of  the  carbonate  of 
bismuth  may  be  given  with  five  grains  of  the  aromatic  chalk  powder,  every 
four  hours  ;  and  a  few  doses  of  this  combination  is  followed  by  really  sur- 
prising improvement  in  many  cases.  If  thought  desirable,  a  drop  of 
laudanum  may  be  added  to  each  alternate  dose  of  this  remedy,  or  a  small 
injection  of  starch  and  opium  may  be  given  every  night. 

When  purging  has  been  arrested,  the  heahng  of  the  ulcers  may  be  pro- 
moted by  perfect  rest,  and  the  administration  of  the  pernitrate  of  iron 
(TFl,  iij.-v.)  with  laudanum  (tt],  j.-ij, )  in  a  teaspoonful  of  water  sweetened  with 
glycerine  ;  or  quinine  may  be  given  with  pepsin  and  strychnia,  as  recom- 
mended during  convalescence  from  inflammatory  diarrhoea.  For  a  con- 
siderable time  it  mil  be  necessary  to  pay  strict  attention  to  the  diet,  and 
limit  the  quantity  of  farinaceous  and  saccharine  foods  ;  and  long  after 
convalescence  is  established,  the  child  should  continue  to  wear  a  flannel 
bandage  round  the  belly  as  a  necessary  p'u-t  of  his  dress. 


CHAPTEE  X. 

INTESTINAL   OBSTRUCTION    (INTUSSUSCEPTION). 

Occlusion  of  tlie  intestine  in  the  child  is  rarely  due  to  any  other  cause 
than  intussusception  or  invagination  of  the  bowel.  Although  any  form  of 
mechanical  obstruction  met  with  in  the  adult  may  conceivably  arise  in  the 
young  subject,  such  lesions  are  so  uncommon  in  early  hfe  that  when  dis- 
covered they  have  been  placed  upon  record,  less  for  their  practical  useful- 
ness, than  for  the  interest  they  may  possess  as  jDathological  cui'iosities. 
Thus,  tlie  bowel  has  been  known  to  be  strangulated  by  peritoneal  bands, 
or  by  the  vermiform  appendix  ;  to  be  obstructed  by  carcinomatous  or 
lymphatic  sweUings  ;  or  to  be  narrowed  by  congenital  strictures.  The 
temporar}^  impaction  of  faecal  matters  which  is  sometimes  found,  is  treated 
of  elsewhere  (see  Constipation).  A  description  of  intestinal  obstruction  in 
the  child  practically  resolves  itself,  then,  into  a  description  of  intussuscep- 
tion, and  the  present  chapter  wiU  be  confined  to  this  subject. 

Causation. — Invagination  of  the  bowel,  although  an  uncommon  ac- 
cident at  any  period  of  hfe,  is  more  often  seen  in  the  young  child  than  in 
the  adult.  Babies  seem  to  be  especially  prone  to  it,  for  a  large  joroportion 
of  the  cases  occur  during  the  first  twelve  months  of  life.  Tliis  comjmra- 
tive  fi-equency  of  the  lesion  in  infancy  is  attributed  by  Rilliet  to  the  looser 
connections  of  the  caecum  in  the  iliac  fossa  at  this  age,  and  also  to  the  im- 
perfect development  of  its  muscular  bands,  which  lessens  its  resistance  to 
the  penetration  of  the  small  intestine  into  its  interior. 

In  infancy,  intussusception  consists  either  of  an  invagination  of  the 
small  intestine  into  the  larger,  or  of  one  portion  of  the  colon  into  another 
portion.  At  a  later  period  of  childhood,  the  intussusception  may  involve 
the  small  intestine  alone,  without  the  larger  gut  being  concerned  in  the 
invagination. 

Infants  and  children  in  whom' this  accident  occurs,  are  usually  sturdy 
and  well  nourished  ;  and  the  illness  takes  places  suddenly,  as  a  rule,  with- 
out being  preceded  by  a  period  of  feebleness  or  a  state  of  ill-health. 
Boys  are  more  subject  to  it  than  girls.  The  causes  which  give  rise  to  it 
are  not  always  easy  to  determine.  Drastic  purgatives,  indigestible  food, 
riolence  of  cough,  external  injurj^,  and  even  rapid  motion,  as  when  a  child 
is  danced  quickly  up  and  down  in  his  parents'  arms,  have  aU  been  quoted 
as  exciting  causes  of  the  lesion.  It  is  certainly  curious  to  find  that  in 
many  of  these  cases  the  symptoms  of  obstniction  were  immediately  pre- 
ceded by  a  fall-  or  other  accident.  In  a  case  which  lately  came  under  my 
own  notice — an  infant  of  ten  months  old — the  first  symptoms  followed  a 
fall  from  his  mother's  bed  on  to  the  floor.  Indeed,  the  child,  when  first 
seen,  had  a  severe  bruise  on  the  temple  and  cheek,  testif}T.ng  to  the  severity 
of  the  accident.  Still,  if  causes  such  as  these  were  alone  capable  of  de- 
termining involution  of  the  bowel,  the  accident  would  be  sui'ety  more 
commonly  met  with  than  it  is.  In  some  recorded  cases,  intussusception 
has  been  preceded  by  intestinal  catarrh ;  and  it  is  conceivable  that  any 
sudden  increase  of  peristaltic  action  may  help  to  induce  it. 

3Iorbid  Anatomy. — In  intussusception,  one  portion  of  the  bowel  is 
forced  or  invaginated  from  above  do\vnwards  into  another  portion  imme- 
diately, continuous  with  it.     At  the  point  of  invagination,  therefore,  a  swell- 


I]N^TUSSTJSCEPTION — MOEBID   AISTATOMY.  669 

ing  is  seen  -svhicla  consists  of  three  thicknesses  of  gut  disiDosecI  one  over 
another.  Firstly,  the  external  investing  tube  ;  secondly,  a  portion  con- 
tinuous \vith  this,  which  has  been  doubled  inwards,  or  inverted  within  the 
first ;  lastly,  the  contained  portion  of  the  bowel  whose  entrance  into  the 
first  constitutes  the  lesion.  Of  these,  the  middle  layer,  which  is  of  course 
reversed  or  turned  inside  out,  has  its  mucous  coat,  now  on  its  exterior,  in 
contact  vnth  the  mucous  coat  of  the  investing  portion  of  the  gut ;  while 
its  peiitoneal  coating,  now  innermost,  is  in  contact  with  the  peritoneal  cov- 
ering of  the  contained  or  invaginated  portion  of  the  bowel. 

The  intussusception  is  formed  not  only  by  the  intestinal  tube,  but  also 
by  the  portion  of  mesentery  in  connection  with  it.  This  being  drawn  in 
with  the  invaginated  portion,  presses  the  latter  to  one  side.  Consequently, 
the  foremost  opening  of  the  contained  segment  is  not  in  the  middle  line, 
but  is  twisted  so  as  to  rest  against  a  part  of  the  investing  sheath.  When 
once  started,  the  invagination  tends  to  increase  by  joeristaltic  action,  the 
increase  being  always  at  the  expense  of  the  outermost  portion,  and  may 
vary  in  degree  from  an  extent  of  a  few  inches  to  several  feet. 

The  consequences  of  the  intussusception  are  occlusion  of  the  intestinal 
canal,  and  obstruction  of  the  circulation  in  the  double  layer  of  bowel 
which  forms  the  invaginated  portion.  The  two  inner  tubes  become  dark 
purple  from  congestion,  and  swollen  ;  and  some  effusion  mixed  with  blood 
is  poured  out  between  the  opposed  mucous  surfaces,  and  also  into  the 
canal  beyond  the  j)oint  of  obstraction.  Lymph  is  afterwards  exuded,  and 
the  opposed  serous  surfaces  become  adherent.  In  some  rare  cases,  the 
inflammation  extends  beyond  the  seat  of  disease,  and  causes  general  peri- 
tonitis ;  in  others,  ulceration  and  perforation  take  jDlace  in  the  investing 
sheath,  owing  to  iiTitation  of  the  end  of  the  contained  portion  ;  and  this  is 
sometimes  seen  to  protrude  through  the  opening  thus  formed,  into  the 
cavity  of  the  peritoneum.  If  the  strangulation  of  the  invaginated  portion 
is  complete,  it  becomes  gangrenous,  and,  in  favourable  cases,  may  be  de- 
tached, piecemeal  or  in  mass,  and  discharged  through  the  anus.  Should 
this  happen,  if  the  adhesions  already  formed  remain  firm,  the  sheath  or 
invaginating  segnnent,  being  united  at  its  free  end  with  the  part  of  the 
bowel  immediately  above  the  point  of  intussusception,  still  forms  with  it  a 
continuous  tube,  although  the  intervening  j^ortiou  has  been  removed. 
Sometimes,  howeVer,  the  adhesions  give  way,  and  then  extravasation  may 
take  place  into  the  peritoneum. 

In  infancy,  it  is  usually  the  small  intestine  which  becomes  invaginated 
into  the  colon.  The  end  of  the  ihum,  with  the  ilio-ceecal  valve,  is  forced 
into  the  caecum.  This,  as  the  intussusception  increases,  penetrates  farther 
and  farther  into  the  colon,  drawing  behind  it  the  ilium,  and  doubUng  first 
the  caecum,  then  the  ascending  colon,  and  afterwards  more  and  more  of 
the  larger  bowel  the  farther  it  extends.  At  last,  it  may  reach  the  rectum, 
and  be  felt  by  a  finger  introduced  through  the  anus.  In  such  a  case,  when 
the  abdomen  is  opened,  the  larger  bowel  seems  in  gTeat  part  to  have  disap- 
peared, and  a  tumour  is  found  occupying,  usually,  the  left  side,  often  the 
iliac  fossa.  This  is  of  a  slate-gTay  coloui',  is  elongated  in  shape,  and 
doughy  to  the  touch.  By  traction,  the  invaginated  portion  can  be  drawn 
out,  although  it  is  usually  soft,  and  is  aj^t  to  tear  in  the  process.  Before 
penetrating  into  the  colon,  the  ilium  may  or  may  not  pass  thi'ough  the 
valve  ;  usually,  it  does  not  do  so,  and  if  a  portion  pass  between  the  lips  of 
the  valve,  it  is  seldom  more  than  a  few  inches. 

Sometimes,  even  in  infancy,  more  often  in  older  children,  the  intussus- 
ception occurs  in  the  course  of  the  small  intestine,  the  colon  taking  no 


670  DISEASE   IjN"   CHILDEE]Sr. 

part  in  tlie  invagination.  When  this  displacement  occurs  in  a  health;^ 
child,  it  of  course  gives  rise  to  symptoms  of  obstruction.  It  may,  how- 
ever, take  place  vrithout  producing  sj'mptoms.  In  examining  the  bodies 
of  children,  especially  if  they  have  died  of  intestinal  catarrh,  or  of  some 
form  of  brain  disease,  it  is  not  uncommon  to  find  portions  of  the  bowel 
invaginated,  often  in  several  places,  without  any  symptoms  of  this  accident 
ha^dng  been  noticed  during  life.  This  form  of  intussusception  usually  oc- 
curs in  the  small  intestine.  It  is  supjDosed  to  take  place  immediately  be- 
fore death  ;  for  the  bowel  is  merely  invaginated,  and  is  not  swollen  or  con- 
gested, or  altered  in  appearance  in  any  way.  Moreover,  it  can  be  readily 
drawn  out  by  a  very  slight  effort. 

Symptoms.  — There  is  some  variety  in  the  symptoms,  g,ccording  to  the 
age  of  the  child  and  the  seat  of  the  invagination.  In  infants  the  intussus- 
ception is  almost  always  at  the  expense  of  the  larger  bowel.  In  older 
children  it  may  be  confined  to  the  jejunum  or  ilium,  without  involving 
the  colon.  The  symptoms  noticed  in  infants,  and  those  aiising  in  older 
children,  must  be  therefore  considered  separately. 

In  the  case  of  an  infant  the  ordinary  history  given  by  the  mother  is 
that  the  baby  was  in  his  usual  health,  when  suddenly  he  gave  a  scream, 
tui'ned  excessively  i^ale,  and  then  cried  violently,  writhing  and  drawing  up 
his  legs  as  if  in  great  suffering.  The  pain  is  not  constant,  for  the  child, 
after  a  time,  ceases  to  cry,  and  Hes  back,  looking  pinched  and  j^ale  ;  but  in 
a  short  time  the  paroxysm  returns,  and  he  screams  and  writhes  as  before. 
"When  the  jDain  first  comes  on,  the  infant  vomits  his  last  meal,  and  the 
vomiting  is  usually  repeated,  especially  if  food  or  medicine  be  given  to 
him.  In  most  cases,  an  aperient  is  at  once  ordered,  and  is  returned  di- 
rectly it  has  been  swallowed.  The  state  of  the  bowels  is  important.  If 
they  are  empty  below  the  point  of  obstruction,  they  remain  obstinately 
confined,  and  the  straining  efforts,  which  are  usually  made,  merely  expel 
mucus  and  blood.  If  the  lower  bowel  contains  any  faecal  matter,  this  is 
discharged  in  a  thin,  loose  state,  shortly  after  the  occurrence  of  the  intus- 
susception. The  stool  may  contain  blood,  and  the  action  of  the  bowels  is 
usually  followed,  after  a  short  interval,  by  fui'ther  straining  and  the  evacu- 
ation of  muciTS  and  blood.  At  this  time,  the  temperatixre  is  not  elevated  ; 
the  belly  is  painless— indeed,  during  the  paroxysms  of  colic,  gentle  frictions 
to  the  belly  seem  to  afford  relief  ;  the  abdomen  is  neither  full  nor  tense, 
and  between  the  attacks  of  pain,  the  child  may  be  often  found  in  his  cot 
lying  upon  his  belly.  Sometimes  the  secretion  of  urine  is  greatly  dimin- 
ished, but  this  is  a  very  variable  symptom,  and  apparently  has  no  refer- 
ence at  all  to  the  seat  of  obstruction.  .Often,  at  this  period,  the  most 
careful  examination  of  the  belly  detects  no  locahsed  swelling  ;  but  after 
a  time,  if  the  abdomen  be  carefully  palpated  during  an  interval  of  rest 
from  pain,  a  distinct  swelling  may  be  perhaps  detected  by  the  fingers 
pressed  deeply  into  the  left  iUac  fossa.  There  may  be  some  tenderness  at 
this  point  if  some  hours  have  elapsed  since  the  occurrence  of  the  accident. 
Later,  the  mass  can  often  be  reached  by  the  finger  introduced  into  the 
rectum,  for  its  tendency  is  to  travel  farther  and  farther  down  the  bowel. 
The  child  sleejDS  but  little  after  the  invagination  has  occurred.  If,  at  the 
first,  he  sleeps  between  the  attacks  of  pain,  he  soon  ceases  to  do  so,  and  re- 
mains wakeful  and  restless,  constantly  whining  and  crying  until  exhausted. 
The  temperature  varies.  Sometimes  it  is  little  altered  from  the  normal 
level.  In  other  cases,  it  begins  to  rise  after  a  few  hours,  and  may  reach 
102°  or  103°.  Directly  symptoms  of  collapse  are  noticed,  the  tempera- 
ture usually  falls  below  the  level  of  health. 


IlSrTUSSUSCEPTION — SYMPTOMS.  671 

The  course  of  the  illness  is  apt  to  vary  according  to  the  degTee  of 
strangulation  of  the  invaginated  segment,  and  the  more  or  less  complete- 
ness of  the  obstruction  to  the  passage  of  the  contents  of  the  bowel.  In  rare 
cases,  the  passage  is  not  completely  occluded,  so  that  faecal  matter  can 
still  make  its  way,  although,  of  course,  in  small  quantity,  through  the 
narrow  channel.  The  constipation  is  then  not  obstinate,  but  the  stools  are 
scanty,  and  consist  more  of  mucus  and  bloody  fluid  than  of  the  ordinary 
constituents  of  an  evacuation. 

The  symptoms  continue  without  improvement.  The  pains  retvirn  at 
intervals.  The  child,  in  some  cases,  turns  away  from  his  bottle  ;  in  others, 
he  sucks  greedily  to  assuage  his  thirst  ;  but,  whether  he  swallow  willingly 
or  not,  the  effect  is  the  same,  and  he  usually  vomits  almost  immediately. 
If  he  vomit  at  other  times,  the  ejected  fluids  consist  of  bile-stained  mucus, 
and  very  rarely  of  fsecal  matter.  The  face  gets  pale  and  more  haggard  ; 
the  eyehds  close  incompletely,  and  the  eyeballs  are  sunken.  Occasionally 
he  sti-ains,  but  only  blood  and  mucus  escape  from  the  rectum.  His  belly 
is  often  tender  over  the  seat  of  the  tumour,  and  may  become  fuller  and 
more  tympanitic,  with  some  tension  of  the  parietes.  Sometimes  the 
sphincter  is  relaxed  and  open. 

The  symptoms  of  collapse  come  on  early  if  the  obstruction  of  the 
bowel  is  complete,  and  usually,  on  the  third  day,  the  child  is  found  in  the 
state  described.  Unless  general  peritonitis  occur,  there  is  seldom  much 
pyrexia  ;  indeed,  the  child,  as  a  rule,  feels  cold  and  damp  ;  and  even  if  the 
internal  temperature  is  higher  than  natural,  the  extremities  feel  cold.  In 
this  state,  he  remains  until  he  dies.  A  convulsive  seizure  may  precede 
death,  and  sometimes  convulsions  occiu-  in  the  course  of  the  illness,  and  arc 
repeated  several  times.  Before  death,  the  invaginated  mass  may  be  perhaps 
seen  to  protrude  for  an  inch  or  two  outside  the  anus,  as  a  dark-coloured, 
elongated  lump.  This,  however,  is  not  common.  When  the  strangulation 
is  complete,  the  disease  seldom  lasts  longer  than  a  week,  and  death  often 
occurs  in  three  or  four  days.  If  the  obstruction  is  not  complete,  the  prog- 
ress of  the  case  is  longer  ;  scanty  loose  motions  may  be  passed  at  inter- 
vals, and  the  child  often  lingers  for  a  fortnight  or  more. 

If,  by  any  means,  the  invaginated  portion  of  the  bowel  can  be  returned, 
the  vomiting  ceases  ;  the  bowels  discharge  a  copious,  semi-fluid,  offen- 
sive stool,  and  the  child  sleeps.  On  waking,  he  takes  the  bottle  or  the 
breast,  and  seems  cheerful  and  contented,  although  necessarily  languid  and 
feeble. 

In  older  children,  the  symptoms  correspond,  in  the  main,  with  those 
already  described,  but  certain  differences  are  noticed.  Thus,  the  disten- 
tion of  the  belly  is  usually  greater  after  the  age  of  infancy,  and  comes  on 
earlier.  It  is  sometimes  extreme,  and  the  coils  of  dilated  intestine  can  be 
made  out  through  the  abdominal  parietes.  Also,  vomiting  is  generally 
persistent,  and  is  apt  soon  to  be  feculent.  The  child  will  take  no  food, 
but  is  excessively  thirsty.  The  discharge  of  blood  from  the  anus  occurs 
less  frequently  the  more  advanced  the  age  of  the  child.  If  the  invagina- 
tion occupy  the  large  intestine,  the  strangulated  portion  of  the  bowel  is 
approached  near  to  the  outlet,  and  haemorrhage  from  the  ruptui-ed  vessels 
is  likely  to  take  place.  If,  however,  the  intussusception  is  higher  up,  and 
is  confined  to  the  small  intestine  without  implication  of  the  colon,  no  haem- 
orrhage at  all  may  be  noticed.  There  is  then,  in  most  cases,  obstinate  con- 
stipation. When  the  stage  of  collapse  comes  on,  the  tongue  becomes  dry, 
and  is  covered  with  a  brown  fur  ;  the  belly  is  tympanitic  ;  the  eyes  are 
sunken,  and  the  face  of  the  child  is  ghastly  and  death-like. 


672  DISEASE  IX   CHILD RElSr. 

If  separation  and  elimination  of  the  gangrenous  portion  of  tlie  bowel 
takes  place,  this  favoui'able  change  is  usually  noticed  in  the  course  of  the 
second  week.  In  these  fortunate  cases,  the  dark-coloured  gangrenous  seg- 
ment of  the  intestinal  tiibe  is  passed  with  much  straining,  and  often  a  quan- 
tity of  dark,  offensive  feculent  matter  comes  away  with  it.  The  amotmt  of 
this  varies,  and  is  often  very  considerable.  The  discharge  is  followed  by 
symptoms  of  great  rehef.  The  child  usually  falls  into  a  profound  sleep 
from  which  he  wakes  greatly  refreshed.  His  tbu'st  is  diminished,  his  appe- 
tite begins  to  return,  and  his  whole  aspect  betokens  gi'eat  improvement. 
The  gangrenous  jDortion  may  not  be  expelled  in  one  piece,  but  sometimes 
comes  away  in  patches  and  shreds,  mixed  with  foul-smeUing  faeces  and 
blood.  After  the  separation  and  discharge  of  the  slough,  recovery  usually 
follows  with  great  rajDidit}'. 

In  the  fatal  cases,  death  results  more  often  from  collapse  than  from  peri- 
tonitis. The  child  becomes  weaker  and  weaker,  and  dies  from  asthenia. 
Sometimes  death  is  j^receded  by  a  convulsive  seizure. 

The  above  is  the  course  of  the  disease  in  infants  and  older  children. 
Of  the  symptoms,  the  sudden  occurrence  of  severe  abdominal  jDain,  the 
vomiting,  the  constipation,  the  discharge  of  blood  from  the  bowel,  and  the 
discovery  of  a  swelling  by  palpation  of  the  beUy  or  exploration  per  anum, 
are  the  most  characteristic. 

The  pain  is  of  an  excruciating  character,  as  is  sho'^Ti  b}'  the  child's 
agonising  cries,  his  restless,  jerking  movements,  and  the  death-like  paUor 
which  spreads  over  his  face.  In  a  case  recorded  by  Dr.  Wilks,  the  infant 
actually  fainted  from  the  intensity  of  his  suffering.  The  paiu  comes  on  in 
paroxysms,  but  these  do  not  occur  at  regular  intervals.  Often,  after  the  fii'st 
access,  the  colic  suddenly  ceases,  and  the  child  appears  to  be  easy.  He  may 
remain  fi'ee  fi'om  j)ain,  showing  no  sign  of  illness,  for  some  hours,  but  sooner 
or  later  the  paroxysms  return.     This  is  most  often  the  case  with  infants. 

Vomiting  is  always  present,  and  may  vary  from  mere  regurgitation  to 
violent  retching.  It  is  often  accompanied  b}^  hiccough.  The  vomited  mat- 
ters consist  of  food  and  medicine,  or,  if  nothing  has  been  taken,  of  mucus 
and  bile.  Occasionally,  blood  is  thrown  up  from  the  stomach.  ]Mi-.  Macleod 
has  recorded  the  case  of  a  male  infant,  aged  six  months,  in  whom  this  symp- 
tom was  noted  before  death.  The  intussusception  had  occurred  in  the 
usual  situation  for  this  age. 

Constipation  is  not  a  constant  sj'mptom.  If  the  bowel  below  the  point 
of  obstruction  contains  faecal  matter,  this  is  invaidably  expelled  early. 
There  is  then  no  alvine  discharge  for  the  remainder  of  the  illness.  In  less 
common  cases  a  certain  amount  of  diarrhoea  may  be  present,  if  the  strangu- 
lation of  the  bowel  is  not  complete ;  for  the  swelling  of  the  invaginated 
segment  becomes  reduced  after  a  few  days,  and  the  cahbre  of  the  canal 
may  be  partially  restored. 

A  discharge  of  blood  and  mucus  is  one  of  the  most  constant  symp- 
toms. The  amount  varies.  In  some  cases,  it  ma}^  be  scanty,  nothing  more 
than  a  stain  of  blood  being  seen  upon  the  diaper  when  the  napkin  is  changed. 
In  other  cases,  the  quantity  may  reach  several  ounces.  It  appeal's  early. 
It  may  be  seen  at  the  time  of  the  first  effort  of  vomiting,  and  is  seldom  de- 
layed longer  than  twelve  hours.  In  infants,  this  symptom  is  almost  invari- 
ably present,  and  may  be  taken  to  indicate  a  degree  of  constriction  of  the 
bowel  stopping  short  of  actual  strangulation  and  complete  arrest  of  cu'cu- 
lation.     In  older  children,  as  has  been  said,  it  may  be  wanting. 

A  distinct  swelling  in  the  course  of  the  bowel,  when  discovered,  is  a 
valuable  diagnostic  sign ;  but  often  it  is  not  present.     The  tumoui*  gener- 


INTUSSUSCEPTION — SYMPTOMS — DIAGNOSIS.  673 

ally  lies  in  the  left  iliac  region,  and  gives  a  firm,  doughy  sensation  to  the 
finger.  It  is  movable,  and  varies  from  a  walnut  to  a  hen's  egg  in  size,  or 
may  even  be  larger.  When  detectable  by  palpation  of  the  belly,  the  tu- 
mour can  often  be  reached  by  the  finger  introduced  into  the  rectum  ;  espe- 
cially if  at  the  same  time  pressure  is  made  upon  the  invaginated  mass  by 
the  other  hand  placed  upon  the  abdomen.  A  rounded  lump,  feeling  very 
much  hke  the  cervix  uteri  in  a  vaginal  examination,  may  then  be  felt  by  the 
point  of  the  finger.  Sometimes  the  mass  can  be  seen  to  protrude  beyond 
the  anus,  but  this  is  exceptional.  Out  of  forty-nine  cases  collected  by  Dr. 
Lewis  Smith,  the  protrusion  occurred  only  in  six. 

Tenesmus  is  usually  present,  and  is  often  distressing.  It  may  cease  as 
the  child's  strength  becomes  reduced. 

'  The  amount  of  fever  varies.  At  first,  the  temperature  is  normal,  but  as 
inflammation  occvirs  in  the  intussusception,  the  bodily  heat  increases,  al- 
though it  is  rarely  excessive.  The  symptom  is  said  to  be  less  marked  in 
infants  than  in  older  children.  The  pulse,  after  the  first  few  days,  is  very 
rapid,  and  as  the  strength  decHnes,  becomes  excessively  frequent  and  fee- 
ble. 

The  duration  of  the  iUness  varies,  as  has  been  said,  according  to  the 
completeness  of  the  strangulation  of  the  bowel,  and  also  according  to  the 
ag3  and  strength  of  the  child.  In  infants,  it  rarely  lasts  longer  than  a 
week,  and  death  often  takes  place  as  early  as  the  fourth  or  fifth  day.  In 
older  childi'en,  the  course  of  the  disease  may  be  equally  rapid  ;  but  often 
it  is  more  protracted,  and  cases  have  been  recorded  in  which  the  lesion 
has  become  chronic,  lasting  several  months.  Separation  and  elimination 
of  the  gangrenous  portion  is  never  seen  in  infancy,  and  is  rare  even  in 
more  advanced  childhood. 

Diagnosis. — When  a  child  who  has  been  previously  in  good  health,  or 
has  suffered  merely  from  looseness  of  the  bowels,  is  suddenly  seized  with 
violent  paroxysmal  colic  and  repeated  vomiting,  followed  immediately,  or 
after  a  few  hours,  by  evacuations  consisting  of  non-fsecal  mucus  and  blood, 
discharged  with  great  straining,  we  may  conclude  that  he  is  suffering  from 
occlusion  of  the  bowels,  due,  in  all  probability,  to  intussusception.  The 
discovery  of  an  oval  tumour,  in  the  left  side  of  the  belly,  will  confirm  us  in 
our  opinion,  and  if  we  can  succeed  in  touching  the  mass,  by  the  finger  in- 
troduced into  the  rectum,  the  sign  is  a  conclusive  one.  The  conjunction 
of  all  the  above  symptoms  is  of  importance,  and  the  absence  of  any  one  of 
them  is  not  to  be  disregarded.  Thus,  if  we  are  called  to  a  child  who  has 
been  taken  suddenly  with  pain  in  the  belly,  and  vomiting,  and  whose  bow- 
els are  obstinately  confined,  we  must  not  conclude  too  hastily  that  an  intus- 
susception has  occurred.  The  pain  may  be  extreme  and  paroxysmal ;  the 
vomiting  frequent  and  distressing ;  and  the  constipation  may  have  resisted 
aperients  and  enemata,  without  obstruction  of  the  bowels  in  any  form  be- 
ing present.  Peritonitis,  which  jjaralyses  the  bowel,  and  induces  vomiting- 
by  reflex  disturbance,  may  pi-oduce  just  such  symptoms.  On  the  other, 
hand,  a  passage  from  the  bowels  may  take  place,  although  intussusception 
has  actually  occurred.  The  appearance  of  one  loose  fsecal  stool,  after  the 
beginning  of  the  illness,  is  common  in  intussusce]3tion,  for  the  contents  of 
the  colon  below  the  point  of  obstruction  are  usually  expelled  shortly  after- 
the  occuiTence  of  the  invagination.  If,  however,  the  bowels  continue  loose, 
and  fsecal  matter  is  afterwards  evacuated,  whether  by  injection  or  other- 
wise, the  symptom  is  not  in  favour  of  intussuscej)tion ;  for,  even  if  the  chan- 
nel become  pervious  later,  after  swelling  has  partially  subsided,  it  is  rarely 
free  during  the  first  two  or  three  days  of  the  illness.  In  such  a  case  we 
43 


674  DISEASE  ijs"  child REisr. 

should  hesitate  to  ascribe  the  symptoms  to  invagination  of  the  bowel,  un- 
less the  other  evidence  in  its  favour  points  irresistibly  to  such  a  conclusion. 

Again,  severe  coUc  in  a  young  baby  is  often  accompanied  by  alarming 
symptoms,  in  which  all  the  signs  of  the  most  violent  pain  may  be  followed 
by  great  prostration.  In  the  attack,  the  child  utters  piercing  screams,  and 
writhes  his  body  exactly  as  he  does  in  intussusception  ;  indeed,  in  almost 
all  cases  of  invagination  of  the  bowel,  we  generally  find  that  an  aperient 
has  been  ordered,  under  the  impression  that  the  spasms  of  jDain  are  the  con- 
sequence of  irritation  of  the  bowels  by  undigested  food,  or  flatulent  disten- 
tion. In  every  case,  therefore,  where  intussusception  is  possible,  we  must 
weigh  the  evidence  very  carefuUy,  as  the  recovery  of  the  child  may  depend 
upon  early  and  accurate  diagnosis  of  his  illness.  In  addition  to  simple 
colic  and  peritonitis,  intussusception  may  be  confounded  with  dysentery; 
with  impaction  of  hardened  fsecal  masses,  and  with  intestinal  haemorrhage 
from  other  causes. 

In  simple  colic  the  pain,  although  often  excessively  severe,  is  not  paroxys- 
mal, with  complete  remissions,  and  usually  ceases  with  the  expulsion  down- 
wards of  a  quantity  of  gas.  The  skin  is  often  hot,  and  the  belly  hard  and  savoI- 
len.  There  is  no  vomiting  or  tenesmus,  or  discharge  of  bloody  mucus  from 
the  bowels.  It  is  very  important  to  attend  to  these  jDoints,  for  the  adminis- 
tration of  castor-oil  or  other  aperient,  which  quickty  cures  an  ordinary  colic, 
cannot  but  be  injurious  in  a  case  of  intussusception,  increasing  the  peris- 
taltic action  of  the  bowels,  and  aggravating  the  invagination. 

Between  jperitonitis  and  actual  obstruction  of  the  bowels,  the  diagnosis 
is  often  very  difficult.  The  form  of  peritonitis  which  is  most  apt  to  simu- 
late intussusception,  is  that  in  which  inflammation  occurs  suddenly  as  a 
consequence  of  ulceration  and  j^erforation  of  the  vermiform  appendix,  with 
extravasation  into  the  peritoneal  cavity.  In  these  cases,  symptoms  similar 
to  those  of  obstruction  may  come  on  quite  suddenly,  and  be  very  severe. 
But  in  peritonitis,  the  temperature  is  always  elevated  from  the  first ;  the 
abdominal  parietes  are  distended  and  tense,  and  pressure  in  the  right 
ihac  fossa  is  painful.  In  intussvisception  there  is  no  pyrexia  at  the  fii'st ; 
the  abdominal  wall  is  lax  and  un distended  ;  there  is  frequent  tenesmus, 
and,  after  a  few  horu's,  blood  and  mucus  are  discharged  fi'om  the  bowel. 
This  last  symptom,  added  to  the  signs  of  intestinal  occlusion,  is  pathogno- 
monic. The  mistake  is  most  likely  to  be  made  when  the  symptoms  occur 
in  a  child  after  the  age  of  infancy,  and  haemorrhage  is  not  present,  or  is 
slow  to  appear.  Still,  even  in  these  cases,  the  absence  of  fever,  the  lax- 
ness  of  the  parietes,  and  the  tenesmus  should  raise  strong  suspicions  of 
the  real  nature  of  the  disease.  In  all  cases  of  doubt,  a  careful  examina- 
tion of  the  belly,  while  the  child  is  under  the  full  influence  of  an  anaes- 
thetic, wiU  usually  enable  us  to  detect  the  presence  of  a  tumour  in  the 
abdomen  if  invagination  has  occui-red. 

It  is  possible  to  mistake  intussusception  for  dysentery,  for  the  mistake 
has  actually  been  made.  In  the  latter  disease,  the  dejections  are  often 
small,  and  consist  of  thick  mucus,  mixed  more  or  less  intimately  with 
blood.  They  are  discharged  with  great  straining  and  pain.  Even  in 
severe  catarrh  of  the  lower  bowel,  which  is  often  improperly  called  "dys- 
entery," much  mucus,  and  often  streaks  or  spots  of  blood,  can  be  observed. 
But  these  s^^mptoms  alone  are  far  from  being  characteristic  of  intestinal 
invagination.  We  miss  the  abru^Dt  onset,  the  frequent  vomiting,  and  the 
lax,  undistended  condition  of  the  belly.  Moreover,  the  whole  course  of  the 
two  diseases  is  different,  and  true  dysentery  is  usually  an  epidemic  malady. 

In  cases  of  impaction  of  faecal  matter — an  accident  which  constitutes  a 


IJSTTUSSUSCEPTIOjSr — PKOGNOSIS — TEEATMENT.  675 

real  occlusion  of  tlie  bowel — the  symptoms  of  invagination  may  he  closely 
simulated.  Vomiting,  colicky  pain,  tenesmus,  and  constipation  may  all  be 
present,  and  on  examination  of  the  belly,  a  firm  tumour  may  be  detected 
through  the  abdominal  i^arietes.  But  in  faecal  accumulation,  there  is  usu- 
ally a  history  of  hard  and  scanty  stools  for  a  considerable  jDeriod  before 
the  attack  ;  the  vomiting  is  much  less  severe,  there  is  no  bloody  mucus 
evacuated  from  the  bowels,  and  the  tumour  is  more  superficial,  does  not 
shift  its  place,  and  can  be  indented  by  firm  pressure  with  the  fingers.  If 
this  condition  be  suspected,  a  large  pui-gative  enema  will  cause  the  tumour 
and  consequent  symptoms  to  disappear. 

Sometimes,  in  intussusception,  the  amount  of  blood  discharged  from 
the  bowel  is  very  copious.  Still,  the  other  S3'mptoms  of  invagination  are 
present,  and  it  is  only  necessary  to  be  aware  that  htemorrhage  may  be  oc- 
casionally profuse,  to  prevent  this  fact  from  casting  any  doubt  upon  the 
correctness  of  the  diagnosis. 

If  attention  be  paid  to  the  symptoms  which  have  been  pointed  out  as 
characteristic  of  intussusception,  we  shall  be  able,  in  most  cases,  to  arrive 
at  a  correct  conclusion.  An  examination  j^si^  anum  should  never  be  neg- 
lected ;  nor,  in  a  doubtful  case,  should  we  omit  to  inspect  the  ordinary  sit- 
uations of  rupture,  for  although  strangulated  hernia  is  rare  in  young 
subjects,  it  does,  occasionally,  occur. 

Prognosis. — When  we  have  satisfied  ourselves  of  the  presence  of  intus- 
susception, the  prognosis  is  excessively  grave.  In  the  young  baby,  in 
spite  of  a  few  recorded  cases  of  spontaneous  reduction  of  the  invaginated 
portion  of  the  bowel,  and  of  others  in  which  remedial  measures  promjDtly 
applied  proved  successful,  any  measures  we  may  resort  to  must  be  under- 
taken with  serious  forebodings.  The  danger  is  in  direct  proportion  to 
the  urgency  of  the  symptoms.  If  the  acuteness  of  the  case  indicates  tight- 
ness of  constriction,  the  prognosis  is  most  serious,  whatever  measures  are 
adopted,  and  however  quickly  assistance  is  rendered.  In  almost  all  cases 
of  successful  reduction  by  taxis,  inflation,  or  injection,  the  symptoms  have 
not  been  very  severe.  To  be  successful,  treatment  must  be  early  ;  but 
delay  is  less  fatal  if  the  constriction  be  only  moderate,  than  when  strangu- 
lation is  complete.  If  the  infant  is  seen  after  the  end  of  the  third  day, 
and  acute  symptoms  have  undergone  no  alleviation,  a  fatal  issue  to  the 
illness  can  hardly  be  doubted. 

In  older  children,  whose  superior  strength  enables  them  to  resist  for  a 
longer  period  the  prostrating  effects  of  the  obstruction,  recovery  by  slough- 
ing and  discharge  of  the  invaginated  segment  is  possible,  and  may  even  take 
place  when  the  child  is  in  extremis,  and  after  all  hope  has  been  abandoned ; 
but  this  is  a  result  which  in  any  individual  case  we  can  never  dare  to  an- 
ticipate. Certainly,  there  are  no  indications  by  which  so  favourable  an  issue 
can  be  foretold.  Even  if  the  evacuation  of  the  slough  by  stool  shows  that 
elimination  has  actually  been  accomplished,  we  must  still  not  be  hasty  in 
declaring  the  danger  at  an  end ;  for  the  greatest  care  will  yet  be  requu-ed 
during  the  period  of  convalescence  to  prevent  the  newly-formed  adhesions 
from  being  injured  or  detached. 

Treatment. — Accuracy  of  diagnosis,  and  especially  early  recognition  of 
the  nature  of  the  complaint,  are  of  great  importance  in  this  disease.  If  the 
real  cause  of  the  vomiting  and  colic  are  discovered  at  the  beginning,  remedial 
measures  may  be  applied  with  greater  hope  of  success.  As  it*is,  medical 
advice  is  seldom  sought  mitil  the  bowel  has  been  irritated  by  one  or  more 
doses  of  aperient  medicine,  to  the  serious  aggravation  of  the  patient's  con- 
dition and  the  lessening  of  his  chances  of  recovery. 


670  DISEASE   IlSr   CHILDEEN. 

The  only  admissible  remedy  is  opium.  This  should  be  given  at  once, 
and  repeated  as  often  as  is  necessary  to  lull  the  pain,  and  keep  the  child 
under  the  influence  of  the  narcotic.  It  is  best  given  by  subcutaneous  in- 
jection, and  may  be  usefully  combined  vpith  atropine.  It  is  well  to  begin 
with  small  quantities,  although  it  will  be  generally  found  that  the  system, 
even  in  infancy,  is  singularly  tolerant  of  the  drug.  For  a  child  of  twelve 
months  old,  one-twentieth  of  a  grain  of  morphia  and  a  sixth  of  a  grain  of  atro- 
pine may  be  used  every  half -hour  until  some  sensible  effect  is  produced  upon 
the  symptoms.  This  not  only  relieves  the  suffering  of  the  patient,  but  also 
tends  to  jDrevent  any  increase  in  the  invagination  and  to  check  the  vomiting. 

If  the  case  is  seen  sufficiently  early,  the  question  of  endeavouring  to  re- 
duce the  invagination  by  mechanical  means  must  be  considered.  Mechan- 
ical interference  is  only  allowable  during  the  first  few  days  of  the  illness, 
before  exudation  of  lymph  has  caused  adhesion  between  the  serous  sur- 
faces ;  and  will  be  useless  if  great  tenderness  on  pressure  of  the  invaginated 
mass  indicates  the  presence  of  inflammation.  The  means  employed  may  be 
taxis,  insufflation  of  air,  or  the  injection  of  water.  Before  proceeding  to  any 
of  these  measures,  the  child,  unless  a  young  habj,  should  be  placed  under 
the  full  influence  of  an  anaesthetic.  Taxis  consists  in  kneading  and  other- 
wise manipulating  the  abdomen  with  the  hand.  This  method  is  generally 
employed  in  conjunction  with  either  of  the  others.  The  child  is  laid  upon 
his  back  with  the  nates  raised  so  that  the  body  is  inclined  at  an  angle  of 
45  degrees.  A  large  quantity  of  tepid  water  is  then  injected  very  slowly 
into  the  bowel  by  a  Davidson's  syringe  capped  with  a  long  tube.  Every 
now  and  again  the  abdomen  must  be  kneaded  with  the  hand  so  as  to  work 
the  fluid  along  the  bowel  upwards  towards  the  obstruction,  and  this  process 
of  taxis  may  be  continued  for  several  minutes.  As  much  fluid  must  be  used 
as  the  bowel  can  be  made  to  contain.  The  best  proof  that  reduction  has 
been  effected  is  sleep.  As  a  rule,  directly  the  child's  more  pressing  symp- 
toms are  reheved,  he  sleeps  at  once.  The  return  of  the  invaginated  bowel 
is  also  sometimes  marked  by  a  discharge  of  blood  and  mucus,  followed  by 
a  copious,  offensive,  semi-fluid  stool. 

Lisufflation  of  air  is  best  suited  to  cases  where  the  intussusception  has 
descended  into  the  rectum  and  an  enema  retiu'ns  at  once.  The  air  may  be 
supplied  by  a  common  bellows,  to  the  nozzle  of  which  a  caoutchouc  tube 
has  been  attached,  terminating  in  a  long  gum-elastic  tube.  Some  lint  must 
be  wrapped  round  the  base  of  this  tube  to  enable  it  to  fit  closely  within  the 
sphincter.  Air  must  be  injected  slowly,  and  at  times  the  belly  should  be 
manipulated  as  in  the  former  case.  The  process  should  be  continued  un- 
til the  large  bowel  is  thoroughly  distended  with  air,  if  this  prove  possible. 
In  a  favourable  case,  the  mass  will  be  felt  to  recede  from  the  left  iliac  region, 
and  then  pass  altogether  from  the  reach  of  the  finger.  If  this  happen,  we 
may  have  great  hopes  of  having  achieved  our  object. 

These  measures  can  only  have  a  chance  of  success  during  the  first  three 
days.  Certainly,  after  the  fourth  we  can  do  nothing  but  harm  by  distend- 
ing the  bowel  with  either  ah'  or  water. 

In  addition  to  the  above  methods,  attempts  have  been  made  to  replace 
the  bowel  by  a  long  sound  passed  into  the  rectum,  and  have  occasionally 
succeeded.  This  method  is,  of  course,  only  applicable  to  cases  where  the 
invaginatioji  is  within  easy  reach  of  the  outlet.  An  sesophageal  bougie  with 
a  sponge  fastened  to  its  end  forms  a  useful  instrument  for  this  purpose. 
If  the  above  measures  prove  ineffectual,  it  becomes  a  question  whether  a  sur- 
gical -operation  should  be  resorted  to,  or  whether  we  should  trust  merely 
to  complete  rest  and  opium. 


INTUSSUSfcEPTION — TEEATMENT.  677 

The  operation  of  opening  the  abdomen  and  reducing  the  invagination 
with  the  fingers  has  been  happily  accompHshed  in  some  cases,  and  may  offer 
a  chance  of  success  when  other  means  have  failed.  Our  decision  as  to  its 
desirability  will  depend  upon  the  opinion  we  have  formed  with  regard  to 
the  tightness  of  constriction  of  the  invaginated  gut.  As  Mr,  Hutchinson 
has  pointed  out,  the  imprisoned  portion  of  the  bowel  may  be  tightly  stran- 
gulated, or  merely  irreducible,  with  comparatively  little  constriction.  In  the 
former  case,  the  course  of  the  disease  is  very  rapid,  and  the  symptoms  are 
severe  ;  gangrene  quickly  supervenes,  and  death  is  speedy.  In  the  latter, 
Avhere  the  channel  often  remains  pervious,  although  much  narrowed,  the 
course  is  more  chronic,  and  the  symptoms  are  less  pressing.  It  is  in  these 
slower  cases  that  the  operation  is  especially  likely  to  be  successful.  Un- 
fortunately, the  difficulty  of  judging  of  the  degree  of  tightness  of  the  con- 
striction is  very  great.  The  severity  of  the  symptoms  is  not  always,  in  chil- 
dren, a  trustworthy  guide.  Much  depends  in  such  a  case  upon  the  nervous 
impressibility  of  the  particular  patient ;  for  a  degree  of  strangulation  which 
in  one  child  will  produce  violent  vomiting  and  early  prostration,  will,  in  an- 
other, be  attended  by  much  less  serioiis  and  urgent  symptoms.  In  young 
babies,  unless  the  operation  be  performed  within  the  first  three  days,  and 
before  the  occurrence  of  collapse,  we  can  have  little  hope  of  its  success  ;  but 
as,  in  such  cases,  the  death  of  the  child,  if  left  alone,  is  certain,  the  operation 
is  surely  a  permissible  one.  In  older  children,  I  am  strongly  of  ojDinion  that 
it  should  not  be  performed  if,  from  violence  of  vomiting,  severity  of  the  gen- 
eral distress,  and  early  occurrence  of  prostration,  we  have  reason  to  believe 
the  strangulation  of  the  bowel  to  be  complete.  The  gut  would  probably 
be  found  either  gangrenous  or  adherent.  In  such  cases  there  is  always  the 
last  chance  of  sloughing  and  elimination,  and  this  the  operation  would  take 
away.  On  the  other  hand,  if  the  general  symptoms  are  comparatively  mild, 
and  especially  if  the  intestinal  channel  is  not  completely  occluded,  the  oper- 
ation is  distinctly  called  for  after  failure  of  other  means  of  reduction. 

In  the  early  period  of  the  illness,  vomiting  is  often  encouraged  by  re- 
peated and  unnecessary  feeding  of  the  child.  At  this  time,  it  is  best  to  give 
no  food  at  all,  and  only  to  allow  an  occasional  spoonful  of  barley-water  to 
assuage  the  thirst.  If  old  enough,  the  child  may  be  allowed  to  suck  lumps 
of  ice.  If  the  vomiting  remits,  some  simple  food — milk  and  barley-water 
for  a  baby,  given  cold  with  a  teaspoon  ;  and  for  an  older  child,  strong  beef- 
tea,  essence  of  meat,  and  milk,  also  in  small  quantities  at  a  time — may  be 
allowed.  When  the  strength  begins  to  fail,  brandy-and-egg  mixture  can  be 
given. 

If  elimination  of  the  gangrenous  segment  take  place,  the  utmost  care 
should  be  observed  that  for  months  afterwards  the  child  eat  sparingly  of 
farinaceous  and  fermentable  articles  of  food,  so  as  to  avoid  injuring  the 
young  adhesion  by  flatulent  distention.  Potatoes,  peas,  and  broad-beans 
should  be  forbidden.  Farinaceous  puddings  and  sweets  should  be  greatly 
restricted  in  quantity.  In  fact,  the  child  should  be  dieted  much  as  if  he  had 
lately  passed  through  an  attack  of  enteric  fever. 


CHAPTEK  XL 

TYPHLITIS  AND  PERITYPHLITIS. 

The  csecum  and  its  appendix  are  liable  to  disease  on  account  of  the  tendency 
to  retention  of  foreign  bodies  and  irritating  substances  in  this  part  of  the 
alimentary  canal.  In  perityphlitis,  the  inflammatory  process  begins  almost 
invariably  in  the  csecum,  and  spreads  thence  to  the  loose  areolar  tissue 
around  it.  In  most  cases,  it  is  the  consequence  of  ulceration  and  perfora- 
tion of  the  wall  of  the  csecum  or  vermiform  appendix. 

Causation,  etc. — Tlie  form  of  perityphlitis  which  is  due  to  ulceration  of 
the  vermiform  process  seems  to  occur  more  often  in  early  life  than  in  later 
years.  Therefore,  childhood  may  be  considered  to  be  one  of  its  predispos- 
ing causes.  It  has  been  noticed  in  an  infant  no  more  than  seven  months 
old ;  but  this  is  very  exceptional.  Usually,  the  child  is  between  four  and 
twelve  years  of  age.     It  is  said  to  be  more  common  in  boys  than  in  girls. 

The  determining  cause  of  typhlitis  is,  no  doubt,  in  most  cases,  constipa- 
tion, with  retention  in  the  cfecum  of  hardened  fsecal  matter,  constituting 
what  Kokitansky  named  "typhlitis  stercoralis."  It  has,  however,  been  also 
attributed  to  cold  and  external  injury.  I  have  known  it  to  occur  during 
convalescence  from  typhoid  fever. 

Perityphlitis  is  commonly  due  to  the  passage  into  the  appendix  of  a  lit- 
tle concretion,  which  is  retained  and  sets  up  inflammation  and  ulceration. 
Hardened  intestinal  concretions  are  often  described  frOm  their  appearance 
as  cherry-  or  date-stones,  but  on  examination  are  almost  invariably  found  to 
consist  of  the  earthy  phosphates  combined  with  inspissated  mucus  and  or- 
dinary fsecal  matter.  They  may  be  formed  aroimd  small  foreign  bodies,  as 
a  shot,  a  pin,  or  a  spicula  of  bone.  In  size,  they  may  resemble  a  pea  or  a 
date-stone.  They  have  a  smooth,  shining,  waxy-looking  surface  of  a  gray- 
ish or  brownish  colour.  Their  consistence  is  hard,  and  their  structure  often 
laminated.  Sir  Wilham  Jenner  is  of  opinion  that  the  retention  of  these  cal- 
culi is  due  in  many  cases  to  malposition  of '  the  appendix.  This  process, 
owing  to  its  length  and  the  attachment  of  its  mesentery,  may  be  bent  at  an 
angle  (instead  of  being  directed  upwards  and  inwards),  so  that  hardened 
particles  can  slip  readily  into  it  but  are  prevented  from  returning.  Accord- 
ing to  Dr.  Sands,  the  appendix,  before  destruction  of  its  coats,  contracts  ad- 
hesions to  the  peritoneum  lining  the  ihac  fossa ;  so  that  when  perforation 
occurs,  the  faecal  matters,  instead  of  entering  the  serous  cavity,  gradually 
pass  into  the  loose  connective  tissue  which  Hes  outside  the  peritoneum. 

In  some  cases,  a  typhoid  or  tubercular  ulcer  may  lead  to  destruction  of 
the  wall  of  the  caecum,  or  the  part  of  the  intestine  immediately  adjoining, 
and  be  a  cause  of  extravasation.  When  the  escape  of  fsecal  matter  takes 
place  into  the  loose  tissue  behind  the  csecum,  it  sets  up  inflammation  and 
abscess.  An  abscess  once  formed  rapidly  enlarges,  and  tends  to  point  some- 
where in  the  iliac  region,  or  in  the  groin  just  above  Poupart's  ligament 
The  du-ection  in  which  the  pus  travels,  varies  according  to  the  exact  seat  of 


TYPHLITIS   AND   PERITYPHLITIS — SYMPTOMS.  679 

tlie  purulent  collection.  ,  Tims  it  vasij  pass  along  tlie  inguinal  canal  into 
the  scrotum,  or  along  the  psoas  and  iliac  muscles  to  the  upper  part  of  the 
thigh.  Sometimes  it  dips  into  the  pelvis,  and  opens  into  the  rectum.  In 
other  cases,  if  the  ulcerated  opening  remain  patent,  the  pus  may  pass 
through  it  into  the  csecum ;  but  often  after  a  time  the  opening  closes  up 
so  as  to  shut  off  all  communication  with  the  abscess. 

Often,  general  peritonitis,  more  or  less  severe,  accompanies  the  peri- 
typhlitis, from  extension  of  the  inflammation.  If,  instead  of  opening  into 
the  sub-serous  tissue,  the  rupture  takes  place  from  the  bowel  or  appendix 
directly  into  the  peritoneal  cavity,  peritonitis  is  set  up  at  once. 

Symptoms. — An  attack  of  typhlitis  begins  suddenly  with  pain  localised 
in  the  right  iliac  fossa  ;  the  child  vomits,  and  the  bowels  are  confined.  The 
pain  is  constant,  and  apparently  severe.  It  is  increased  by  pressure  over 
the  caecum,  by  cough,  or  by  efforts  to  vomit.  The  matters  ejected  consist 
of  watery  and  bilious  fluids,  and  the  retching  may  be  severe  and  distressing. 
At  the  same  time,  there  is  fever  which  varies  according  to  the  nervous  im- 
pressibility of  the  child.  Usually,  the  thermometer  marks  101°  or  102°. 
The  expression  of  the  face  is  anxious  and  distressed.  On  paljaation  of  the 
belly,  we  notice  a  firm  mass  in  the  situation  of  the  ctecum,  and  gentle  per- 
cussion at  this  spot  elicits  a  dull  sound.  On  account  of  the  tenderness,  it  is 
difficult  to  make  a  satisfactory  examination  of  the  iliac  region,  for  the  least 
touch  causes  severe  suffering.  The  child  lies  on  his  back,  inclining  to  the 
right  side ;  he  flexes  his  thigh,  and  cries  bitterly  if  any  attempt  is  made  to 
straighten  the  limb.  Sometimes  a  distinct  swelling  may  be  noticed  at  the 
seat  of  pain. 

These  attacks  are  often  spoken  of  as  "cohc"  or  "inflammation  of  the 
bowels ; "  and  after  recovery,  a  tendency  appears  to  be  left  to  a  recurrence  of 
the  illness,  for  it  is  not  uncommon  to  hear  that  this  is  not  the  first  time  that 
the  child  has  suffered  from  similar  symptoms.  As  a  rule,  if  the  lesion  re- 
main simple,  and  be  not  complicated  with  ulceration  of  the  wall  of  the  bow- 
el, its  course  is  rapid  ;  and  in  a  few  days,  under  suitable  treatment,  the  pain 
and  tenderness  are  no  longer  complained  of,  and  the  child  is  convalescent. 
In  exceptional  cases,  the  disease  lasts  into  the  second  week,  and  the  tender- 
ness and  sweUing  only  slowly  subside. 

Perityphlitis  may  be  preceded  by  the  symptoms  described  above  as  being 
characteristic  of  inflammation  of  the  caecum  ;  but  more  often — probably  on 
account  of  the  more  limited  area  occupied  by  the  morbid  process — the  stage 
of  ulcerative  destruction  passes  ahnost  unperceived. 

In  the  first  case,  the  vomiting  and  constipation  cease,  and  the  more  acute 
pain  gives  place  to  a  dull  aching,  or  even  altogether  subsides.  Still,  there 
is  tenderness,  and  the  sweUing  does  not  entirely  disappear.  The  child  does 
not  seem  well.  His  face  retains  an  expression  of  distress,  and  he  is  dull  and 
listless  and  unwilling  to  play  about. 

If  the  perforation  occur  without  having  been  preceded  by  the  symptoms 
of  typhlitis,  there  is  often  nothing  but  a  sense  of  dull  aching  or  disc(Mnfort 
in  the  right  iliac  region,  vnth  occasional  passing  attacks  of  more  acute  pain. 
On  these  occasions,  there  is  vomiting  of  short  duration,  and  the  child  looks 
ill,  and  is  feverish.  This  passes  oft'  in  the  course  of  a  few  hours,  and  the 
child  remains  as  before — not  quite  well,  but  suffering  from  ill-defined  symp- 
toms to  which  little  importance  is  attached.  He  is  peevish  and  fretful, 
capricious  in  his  appetite,  subject  to  attacks  of  diarrhoea  alternating  with 
constipation,  and  often  thirsty  at  night,  with  some  increase  in  his  tempera- 
ture. 

When  perforation  occurs,  if  extravasation  take  place  into  the  perito- 


680  DISEASE   IE"   CHILDREN. 

neum,  all  the  signs  and  symptoms  of  a  localisefl  peritonitis  are  at  once 
observed.  There  is  pain,  swelling,  and  tenderness  in  the  right  side  of  the 
belly,  with  vomiting,  constipation,  high  fever,  a  furred  tongue,  and  a 
pinched,  haggard  face.  The  child  hes  on  his  back  with  his  thighs  flexed, 
and  dreads  the  least  touch.  The  inflammation  may  become  general,  and 
the  child  quickly  die  with  all  the  symptoms  elsewhere  described  (see 
Acute  Peritonitis).  If  it  remain  hmited,  he  may  perhaps  recover  after  a 
longer  or  shorter  illness. 

When  the  perforation  takes  place  posteriorly,  so  that  the  extrava- 
sated  matters  pass  backwards  into  the  loose  connective  tissue  behind  the 
ceecum,  the  symptoms  ai-e  less  severe.  In  such  cases,  the  child  at  first  may 
continue  to  be  about.  He  generally  looks  ill,  has  a  more  or  less  febrile 
temperatui-e,  a  capricious  appetite,  and  is  listless  and  languid.  He  may 
suffer  from  pain  in  the  iliac  region — not  very  severe,  but  constant  and 
wearing ;  or  may  be  attacked  by  occasional  pains  of  a  colicky  character, 
which  are  often  excited  by  movement.  At  night,  the  child  is  restless, 
constantly  altering  his  position,  and  sometimes  crjing  out.  At  this  j^eriod, 
the  bowels  are  usuaUy  confined.  On  examination  in  the  early  stage,  before 
any  pointing  of  the  abscess  has  occui'red,  there  will  often  be  noticed  a  ful- 
ness in  the  right  iliac  fossa,  and  this  pai't  is  tender  when  pressed  upon. 

In  most  cases,  the  child,  if  he  continue  able  to  leave  his  bed,  is  noticed 
to  walk  with  a  limp.  Soon,  however,  he  ceases  to  be  able  to  walk  at  all, 
and  Hes  in  bed  on  his  back  with  his  right  thigh  partially  flexed.  If  he  be 
assisted  to  stand,  he  is  seen  to  rest  his  whole  weight  on  the  left  limb,  and 
to  keep  his  right  limb  partially  bent  both  at  the  hip  and  knee,  and  rotated 
outwards;  With  these  symptoms,  especially  if  there  be  any  history  of  a 
blow  or  fall,  disease  of  the  hip-joint  may  be  suspected.  This  opinion  is 
often  strengthened  by  the  child's  complaining  of  pain  in  the  knee  as  weU 
as  in  the  groin,  and  by  the  suffering  caused  by  any  attempt  at  extension 
of  the  hip.  If  the  tenderness  is  great,  any  rough  manipulation  of  the 
limb,  as  in  rotating  the  head  of  the  thigh-bone,  or  communicating  any 
concussion  to  the  hix3,by  striking  the  knee,  may  be  a  cause  of  pain  in. the 
groin. 

As  the  disease  progresses  and  suppuration  occurs,  the  pallor  and  dis- 
tressed expression  of  the  patient  are  very  noticeable.  His  pyrexia  becomes 
more  marked,  and  the  evening  rise  is  followed  by  depression,  with  sweating 
in  the  morning.  He  loses  flesh  fast,  and  his  tongue  becomes  dry  and 
brown.  The  constipation  now  usually  gives  place  to  diarrhoea,  which  may 
be  copious ;  and  the  pulse  is  very  rapid  and  feeble.  Great  pain  is  com- 
plained of  in  the  belly  which  may  be  distended,  or  even  tympanitic ;  and 
the  swelling  in  the  right  iliac  fossa  increases  in  size,  biit  becomes  softer. 
Sometimes  severe  pains  are  complained  of  in  the  right  knee  and  ankle, 
and  oedema  of  the  limb  may  occur  from  interference  with  the  venous 
circulation. 

If  the  course  of  the  pus  be  downwards  to  the  pelvis,  so  as  to  show  no 
signs  of  pointing  externally,  these  symptoms,  coupled  with  the  resemblance 
of  the  local  condition  to  hip  disease,  may  suggest  a  secondary  tuberculosis. 
But  a  careful  examination  of  the  belly  will  usually  detect  considerable 
fulness  and  tension  in  the  situation  of  the  cascum.  If  the  pus  discharge 
itself  into  the  rectum  or  bowel,  great  relief  is  experienced,  and  the  local 
swelling  and  tenderness  undergo  considerable  diminution.  Often,  the 
course  of  the  pus  is  towards  the  surface  in  the  neighbourhood  of  the 
abscess.  The  skm  then  becomes  darkish  red  or  purple,  and  swollen.^  It 
gives  a  doughy  sensation  to  the  touch,  and,  on  pressui'e,  we  may  notice  a 


TYPHLITIS   AND   PEEITYPHLITIS — SYMPTOMS.  681 

slight  emphysematous  crepitation.      An  incision  into  the  softened   skin 
allows  the  escape  of  brownish,  offensive  pus  and  bad-smelhng  gas. 

These  cases  generally  end  fatally.  If  peritonitis  occur,  either  from 
direct  rupture  or  extension  of  the  inflammation,  death  usually  ensues  in 
a  day  or  two.  If  a  fsecal  fistula  remain  oj)en,  life  may  be  preserved  for  a 
considerable  time — often  for  years.  In  most  cases,  unless  the  abscess  have 
pointed  early,  the  child  is  so  much  reduced  by  pain  and  hectic  fever  that 
he  does  not  long  survive  the  opening  of  the  abscess. 

A  little  girl,  aged  thu-teen  years,  had  an  attack  of  typhoid  fever  when 
eight  years  old.  After  that  time  she  was  subject  to  occasional  attacks  of 
*'  colic "  and  vomiting.  Early  in  December  she  was  ill  with  what  was 
called  "  inflammation  of  the  bowels  with  colic,"  but  recovered  for  the  time. 
In  the  middle  of  February  her  bowels  became  very  much  confined,  and 
after  four  days'  constipation,  she  had  faecal  vomiting.  An  injection  was 
given,  and  a  large  amount  of  faecal  matter  was  brought  away. 

When  admitted  into  the  hospital  on  February  21st,  the  child  looked  ill, 
and  was  very  pale.  The  belly  was  distended  and  tympanitic,  with  some, 
uniform  tension  of  the  parietes,  but  no  tenderness  or  fluctuation.  She 
complained  of  shght  colicky  jDain  at  times.  Her  tongue  was  covered  with 
brownish  fui-,  and  was  inclined  to  be  dry.  There  was  no  sickness.  The 
bowels  had  been  confined  since  the  injection  two  days  before.  The  tem- 
perature at  6  P.M.  was  93.4°. 

The  bowels  were  unloaded  by  repeated  doses  of  an  aperient  saline. 
Afterwards,  small  quantities  of  laudanum  were  given  to  reheve  the  colicky 
pains  which  still  returned  at  intervals  ;  and  the  child  was  kept  quiet  in 
bed,  with  hot  applications  to  her  belly.  After  this,  the  bowels  continued 
to  act  twice  a  day,  and  the  stools  were  normal. 

On  March  3d  it  was  noted  :  "Face  pale  ;  expression  distressed  ;  abdo- 
men not  full  or  tender.  The  temperatiire  since  admission  has  varied,  some- 
times reaching  101°."  A  week  afterwards  the  child  complained  of  more 
pain  in  the  belly,  but  this  part  was  not  swollen  or  tender.  The  bowels  were 
a  httle  relaxed.  The  child  began  now  to  lose  flesh  fast.  She  continued  pale 
and  very  haggard-looking  ;  but  although  she  complained  of  occasional  jDains 
in  the  belly,  there  was  no  tenderness  or  swelling,  and  she  never  vomited. 
The  diarrhoea,  however,  continued.  On  March  14th,  she  began  to  locaHse 
the  abdominal  pain  in  the  right  side  just  over  the  situation  of  the  qviad- 
ratus  lumborum.  The  abdomen  was  natui'al  in  appearance,  and  not  tender. 
The  bowels  were  still  loose,  and  the  stools  Hquid  and  homogeneous,  without 
blood  or  slii'eddy  matter. 

After  a  few  days,  a  fluctuating  tender  swelling  appeared  just  below  the 
ribs  on  the  right  side,  and  in  front  of  the  mass  of  the  quadratus  lumborum. 
This  grew  larger,  and  there  was  much  subcutaneous  oedema  around  the  swell- 
ing. The  child  looked  ill,  and  wasted  rapidly.  Her  temjDerature  was  be- 
tween 100°  and  101°.  The  sweUing  was  opened  by  the  aspirator,  and  an 
ounce  of  brownish,  fetid  pus  was  removed.  The  child,  however,  sank  and 
died  two  days  afterwards. 

On  examination  of  the  body,  a  large  abscess  was  found  at  the  back  of 
the  caecum,  containing  much  purulent  brown  matter.  The  ihum  just  above 
the  ilio-caecal  valve  was  distended,  and  an  ulcerous  opening  was  found  in 
the  wall  just  above  its  junction  with  the  caecum.  A  probe  could  be  passed 
thi'ough  this  opening  into  the  abscess.  There  was,  besides,  some  slight  but 
general  peritonitis.  The  liver  was  fatty,  and  both  it  and  the  spleen  were 
adherent  to  the  diaphragm.  Many  of  the  mesenteric  glands  were  enlarged. 
This  case  of  peritj^jhlitis,  although  really  the  consequence  of  ulceration 


682  DISExVSE   I]S"^    CHILDEEN. 

of  the  small  bo'wel,  and  not  of  the  csecum,  illustrates  very  well  the  ordinary 
history  and  symptoms  of  the  disease.  The  early  attacks  of  colic,  accom- 
panied by  vomiting,  were  no  doubt  owing  to  the  occasional  occiu-rence  of 
inflammation  in  this  part  of  the  intestinal  tube  ;  but  the  ulcerative  process 
probably  dated  only  from  the  illness  from  which  the  child  had  suffered  in 
the  previous  December.  This  was  probably  a  more  severe  attack  of  local- 
ised enteritis.  The  treatment  jDursued  in  this  case  is  not  to  be  recom- 
mended for  hnitation.  Repeated  aperients  under  such  circumstances  as 
must  have  existed  when  the  child  came  under  observation,  could  only  be 
injurious.  It  would  have  been  more  judicious  to  have  left  the  bowels  alone, 
or  to  have  administered  a  simple  enema. 

Cases  of  ulcerative  perforation  of  the  vermiform  appendix  require  spe- 
cial mention.  This  accident  is,  as  has  been  said,  niore  common  in  early  life 
than  after  adult  age  has  been  reached.  Often,  the  initial  stage  of  the  dis- 
ease has  excited  no  notice,  and  the  fii'st  symptoms  that  arise  are  due  to  the 
extravasation  of  the  contents  of  the  bowel  into  the  peritoneum.  In  most 
.cases,  all  the  symptoms  of  acute  peritonitis  ensue,  and  the  child  rapidly 
dies.  The  consequences  of  the  extravasation  are  not,  however,  always  so 
easy  of  recognition.  In  the  chapter  on  Acute  Peritonitis,  mention  is  made 
of  the  occasional  latency  of  the  abdominal  symptoms  in  cases  w^here  the 
peritoneum  is  inflamed.  This  is  sometimes  the  case  when  the  inflamma- 
tion is  set  up  by  matters  extravasated  from  the  bowel ;  and  we  may  find,  as 
a  result  of  ^perforation  of  the  appendix,  merely  pain,  vomiting,  constipation, 
and  some  fever — symjotoms  which  are  not  characteristic  of  peritonitis,  but 
tend  rather  to  suggest  obstruction  of  the  bowel.  In  fact,  not  once,  but 
many  times,  such  cases  have  been  treated  for  obstruction,  even  to  the  extent 
of  actual  surgical  interference.  The  obstinacy  of  the  constipation,  the  iDer- 
sistency  of  the  vomiting,  and  the  colicky  character  of  the  pain,  make  the 
resemblance  curiously  close.  Often,  indeed,  veiy  careful  examination  is  re- 
quired to  detect  the  real  natui-e  of  the  attack.  It  is  of  extreme  importance 
to  remember  that  traumatic  peritonitis  in  the  child  may  be  ushered  in  by 
such  symptoms ;  and  m  every  case  of  siipposed  obstruction  of  the  intestine, 
we  should  search  carefully  for  some  other  cause  for  the  iUness. 

Sometimes,  on  inquiry  we  find  that  on  previous  occasions  the  child  had 
complained  of  slight  abdominal  pain,  lasting  for  twenty-four  hours,  or 
perhaps  two  days,  with  tenderness  in  the  csecal  region  and  a  single  effort 
of  vomiting.  These  passing  attacks  may  be  accompanied  by  flatulence, 
constipation,  or  diarrhoea,  and  a  feeling  of  distention  of  the  belly.  They 
are  due,  no  doubt,  as  Dr.  With  has  pointed  out,  to  ulceration  of  the  vermi- 
form aj)pendix,  with  commencing  adhesive  peritonitis.  After  perforation 
has  occurred,  the  local  symptoms  may  remain  Umited  to  the  iliac  region, 
or  may  spread  to  the  whole  abdomen.  In  the  first  case,  if  the  disease  be 
recognised  and  properly  treated,  the  child  may  perhaps  recover  ;  in  the 
second  case,  he  usually  dies.     Ileus  may  occur  before  death. 

Diagnosis. — Tj^hlitis  is  accompanied  by  such  characteristic  symptoms 
that  its  detection  is  not  a  matter  of  difficulty.  A  sudden  attack  of  abdom- 
inal pain  and  tenderness  referred  to  the  region  of  the  right  ihac  fossa, 
accompanied  by  vomiting,  constipation,  a  pinched,  anxious  exjDression,  and 
some  fever,  at  once  draws  attention  to  the  belly.  On  examination,  the 
presence  of  an  intensely  tender  swelling  in  the  situation  of  the  csecum, 
together  with  the  drawing  up  of  the  thigh  on  the  affected  side,  sufficiently 
indicates  the  nature  of  the  illness.  If  the  occurrence  of  vomiting  and 
obstinate  constipation,  combined  with  a  localised  swelHng  and  severe 
abdomiiial  pain,  should  suggest  intussusception,  we  may  remember  that 


TYPHLITIS   AND   PEEITYPHLITIS — DIAGNOSIS.  683 

in  the  latter  disease* tenderness  and  signs  of  local  peritonitis  are  not  early 
symptoms  ;  that  the  tumour,  if  felt,  is  commonly  detected  on  the  left  side 
of  the  abdomen  ;  and  that  violent  straining,  with  the  passage  of  bloody 
mucus,  is  a  very  constant  and  prominent  symptom. 

If,  after  the  signs  of  general  constitutional  disturbance  have  subsided, 
the  local  symptoms  do  not  disappear,  but  more  or  less  tenderness,  pain, 
and  swelling  persist ;  or  if,  after  disappearing,  the  acute  symptoms  return 
after  only  a  short  interval,  and  this  recurrence  happens  several  times,  in 
either  case  we  have  reason  to  fear  that  the  inflammatory  process  is  going 
on  to  ulceration.  The  occurrence  of  peritonitis  at  this  time  will  confirm 
our  apprehensions,  and  indicate  extravasation  into  the  cavity  of  the  peri- 
toneum. If,  however,  the  wall  be  perforated  posteriorly,  and  an  abscess 
form  behind  the  cascum,  the  symptoms  are  much  less  striking. 

If  the  patient  be  not  confined  to  his  bed,  he  often  complains  of  tender- 
ness in  the  right  groin,  and  halts  upon  the  right  leg.  The  case  is  then 
distinguished  from  hip  disease  by  noticing  that  although  the  child  keeps 
the  thigh  partially  flexed,  and  is  greatly  distressed  when  any  attempt  is 
made  at  passive  extension,  the  head  of  the  femur  may  be  rotated  readily 
and  without  pain,  if  it  be  done  with  care  ;  and  that  pressure  upon  the  hip- 
joint  on  or  behind  the  trochanter,  causes  no  discomfort  if  the  patient's 
whole  body  be  not  jolted  at  the  same  time.  Often,  the  child,  while  lying 
on  his  back,  will  readily  flex  the  thigh,  and  perform  the  movements  of 
abduction  and  adduction.  It  is  only  extension  which  appears  to  be  im- 
possible, and  any  attempt  to  straighten  the  limb  causes  severe  pain.  It 
will  be  remarked,  too,  that  while  the  history  indicates  shortness  and 
acuteness  in  the  illness,  the  symptoms,  if  they  could  be  referred  to  the 
hip-joint,  would  suggest  disease  of  considerable  duration.  Lastly,  wasting 
of  the  muscles  of  the  thigh,  which  occurs  early  in  acute  hip  disease,  is 
absent ;  the  gluteal  muscles  on  the  affected  side  are  not  flattened,  nor  is 
the  fold  of  the  buttock  lowered ;  the  fold  in  the  groin  below  Poupart's 
ligament  is  not  obliterated  ;  and  distinct  swelling  and  tenderness  can  be 
detected  in  the  right  iliac  fossa. 

Directly  signs  of  pointing  are  noticed,  any  remaining  obscurity  in  the 
case  must  disappear. 

Ulceration  and  perforation  of  the  vermiform  process  are  very  difficult 
to  recognise  with  certainty,  as  the  first  symptoms  noticed  are  often  those 
due  to  the  extravasation  into  the  peritoneal  cavity.  Severe  peritonitis 
coming  on  suddenly,  especially  if  the  pain  and  tenderness  can  be  ascer- 
tained to  have  started  from  the  right  iliac  region,  is  very  suspicious  of 
this  accident.  Essential  peritonitis  comes  on  gradually,  and  the  ordinary 
forms  of  peritonitis  from  perforation  are  preceded  by  some  severe  acute 
illness.  It  is  important  to  bear  in  mind  that  the  phenomena  resulting 
from  perforation  of  the  csecal  appendix  may  be  far  from  characteristic  of 
inflammation  of  the  peritoneum ;  and  in  every  case  where  symptoms  arise 
pointing  to  sudden  obstruction  of  the  bowels  (pain,  vomiting,  and  consti- 
pation), accompanied  by  fever,  we  should  carefully  exclude  this  and  other 
possible  causes  of  such  symptoms  before  committing  ourselves  to  the 
diagnosis  of  intestinal  occlusion. 

Prognosis. — Simple  typlilitis  almost  always  ends  favourably ;  but  if 
perforation  occur,  and  extravasation  take  place  into  the  peritoneum,  re- 
covery rarely  follows.  If  a  retro-peritoneal  abscess  result  from  the  per- 
foration, the  prognosis  is  less  unfavoui'able  ;  but  here,  too,  the  patient 
often  dies  from  exhaustion,  or  from  extension  of  the  inflammation  to  the 
serous  membrane.    The  most  favourable  coiu'se  is  that  in  which  the  abscess 


684  DISEASE   m   CHILDEEJSr. 

discliarges  itself  again  into  the  bowel.  Of  the  cases  where  it  opens  ex- 
ternally, a  large  proportion  die.  Perforation  of  the  csecal  appendix  is 
usually  fatal. 

Treatment. — In  every  case  of  typhlitis  our  chief  care  should  be  to  quiet 
peristaltic  action,  and. prevent  any  movement  of  the  bowels,  by  the  free  use 
of  opium.  Whether  the  inflammation  has  had  its  origin  in  a  collection  of  ive- 
cal  matter  in  the  csecum,  or  has  been  induced  by  other  causes,  the  same 
necessity  exists  for  keeping  the  bowels  at  rest  until  the  inflammation  has 
subsided.  Therefore  an  aperient  in  any  shape  is  not  to  be  thought  of  for 
a  moment.  Even  enemata  would  be  injurious  while  the  acute  symptoms 
continue. 

The  child  should  lie  in  bed,  with  a  small  pillow  under  his  right  knee ; 
and  hot  linseed-meal  poultices  should  be  applied  to  the  right  side  of  the 
belly,  and  be  frequently  changed.  Opium  should  be  given  by  the  mouth. 
A  child  of  eight  years  of  age  will  take  three  drops  of  laudanum  every  four 
hours.  If  this  be  vomited,  morphia  (one-sixteenth  to  one-twelfth  of  a  grain) 
can  be  injected  subcutaneously  in  its  stead.  The  vomiting  is,  however, 
usually  checked  by  the  opiate,  and  the  second  attempt  to  administer  it  in 
a  draught  is  often  successful.  A  good  combination  in  these  cases  is  that 
of  the  tinctures  of  opium  and  belladonna.  The  latter  drug  is  not  only  of 
great  service  in  most  forms  of  arrested  function  of  the  bowels,  but  also 
by  its  antagonistic  action  tends  to  modify  the  narcotic  influence  of  the  laud- 
anum without  interfering  with  its  power  as  a  sedative.  If  this  combination 
be  used,  five  drops  of  tincture  of  opium  may  be  given  with  twenty  of  the 
belladonna  tincture  three  times  a  day  to  a  child  eight  years  of  age. 

If  the  child  be  very  strong,  and  the  tenderness  severe,  three  or  four 
leeches  should  be  applied  to  the  painful  spot. 

The  diet  must  consist  of  milk  and  broth,  given  in  small  quantities  at  a 
time.  The  milk  should  be  diluted  with  an  equal  quantity  of  barley-water, 
to  separate  the  particles  of  curd  and  prevent  their  coagulating  in  a  lump. 
It  should  be  also  alkalinised  by  fifteen  or  twenty  drops  of  the  saccharated 
solution  of  lime  to  the  teacupful. 

When  the  acute  symptoms  subside  the  bowels  will  generally  act  spon- 
taneously. If  they  do  not,  an  injection  can  be  administered.  Purgatives 
of  any  kind  should  be  avoided  for  some  time  after  convalescence  is  estab- 
lished. We  can  never  be  sure  that  some  slight  ulcerative  process  is  not 
going  on,  and  the  only  hope  of  the  child  in  such  a  case  would  be  the 
establishment  of  sufficient  adhesions  to  prevent  rupture  and  extravasation. 
Such  adhesions,  if  formed,  an  aperient  would  probably  destroy. 

In  cases  where  we  have  reason  to  suspect  the  presence  of  a  retro-csecal 
abscess,  the  same  reason  for  the  avoidance  of  purgatives  exists.  The  child 
should  be  kept  in  bed,  and  hot  applications  should  be  applied  to  the  pain- 
ful part.  He  should  be  fed  with  nourishing  food  in  small  quantities  at  a 
time ;  and  a  suitable  proportion  of  stimulant  should  enter  into  his  diet. 
Minced  mutton  and  chicken,  strong  beef-essence,  yolk  of  egg,  milk  and 
toast  should  form  the  staple  of  his  food.  If  the  bowels  are  obstinately  con- 
fined, or  faecal  vomiting  occur,  an  enema  may  be  administered,  but  purga- 
tives should  be  avoided.  For  medicine,  quinine  and  a  mineral  acid,  with 
small  doses  of  strychnia  may  be  given,  and  as  the  child  grows  weaker,  am- 
monia and  bark.  Directly  signs  of  pointing  are  noticed  the  pus  should  be 
let  out  at  once. 

If  peritonitis  occur,  the  treatment  must  be  conducted  as  directed  in  the 
chapter  treating  of  that  subject. 


CHAPTER  XII. 

ACUTE  PERITONITIS. 

Acute  peritonitis  may  occur  in  childhood  at  any  age.  It  may  be  pres- 
ent in  the  foetus,  usually  as  a  consequence  of  syphilis,  and  is  then  a  frequent 
cause  of  miscarriage.  It  may  arise  in  the  new-born  infant  as  a  result  of 
pyeemic  infection,  and  is  invariably  fatal.  It  may  occur  at  a  later  period  of 
infancy  or  in  childhood,  either  as  a  primary  disease,  or  as  a  secondary  mal- 
ady complicating  the  course  of  some  other  illness.  The  infective  form  of 
peritonitis  which  occurs  in  the  new-born  baby,  and  is  accompanied  by  jaun- 
dice, is  described  elsewhere  (see  Jaundice).  The  present  chapter  deals  only 
with  the  disease  as  it  is  seen  m  later  infancy  and  childhood. 

Causation. — As  in  the  adult,  inflammation  of  the  peritoneum  in  children 
is  often  induced  by  traumatic  causes.  A  blow  or  other  injury  to  the  abdo- 
men will  occasionally  excite  it,  and  it  may  arise  as  a  consequence  of  punc- 
ture of  a  hydatid  cyst.  The  commonest  of  these  causes  is  the  extravasation 
of  fluids  from  the  bowel  into  the  peritoneal  cavity,  owing  to  perforation  of 
the  intestine.  In  typhoid  fever,  and  in  ulceration  of  the  vermiform  appen- 
dix or  of  the  csecum,  this  accident  may  happen,  and  a  rapidly  fatal  issue  to 
the  illness  usually  follows.  Dr.  Robert  Lee  has  referred  to  two  cases  in 
children,  aged  respectively  eight  and  nine  years,  in  whom  perforation  of  the 
stomach  induced  the  peritonitis.  Sometimes  a  local  inflammation  of  the 
peritoneum  may  become  diffused,  as  when  a  typhlitis  or  perityphlitis,  or 
an  invaginated  portion  of  the  intestine  sets  up  general  peritoneal  inflam- 
mation. Mr.  Curling  has  recorded  the  case  of  a  Httle  boy,  aged  two  years, 
in  whom  the  bruising  of  an  undescended  testicle  produced  this  result. 
Again,  inflammation  may  extend  from  the  chest  to  the  abdomen.  I  can 
now  recall  several  cases  in  which  a  pleurisy  has  been  followed  by  general 
inflammation  *of  the  peritoneum.  I  have  known  this  to  happen  in  the  first 
week  of  the  illness,  before  the  fluid  had  had  time  to  become  purulent ;  but 
in  most  cases  it  occurs  later,  as  a  result  of  the  passage  of  purulent  infective 
matter  from  the  pleural  cavity  along  the  lymphatics  of  the  diaphragm  to 
the  peritoneum.  In  order  that  this  extension  should  occur,  there  must,  no 
doubt,  be  present  some  special  conditions  conferring  pecuHar  infective 
properties  upon  the  purulent  contents  of  the  thorax.  Dr.  Burney  Yeo  has 
described  the  case  of  a  schoolboy,  between  eleven  and  twelve  years  of  age, 
who  was  attacked  in  the  course  of  whooping-cough  by  pleuro-pneumonia 
of  the  left  side  of  the  chest.  Nineteen  days  afterwards  this  was  followed 
by  general  peritonitis,  and  the  patient  very  rapidly  succumbed.  The  same 
unfortunate  accident  happened  to  a  little  boy,  eighteen  months  old,  under 
my  care  in  the  East  London  Children's  Hospital.  The  child  had  an  attack 
of  pleurisy.  As  the  fluid  did  not  become  absorbed  his  chest  was  punctured 
and  a  quantity  of  purulent  matter  was  evacuated.  The  operation  had  to 
be  repeated  several  times,  and  at  last,  as  the  purulent  fluid  still  continued 
to  reaccumulate,  a  permanent  opening  was  estabUshed  in  the  chest-wall. 


.686  DISEASE   IN   CHILDEElSr. 

Tlie  boy  seemed  to  be  going  on  fairly  well  when  extension  of  tlie  inflam- 
mation suddenly  took  place  to  the  peritoneum  and  lie  soon  died. 

Peritonitis  is  sometimes  a  complication  of  the  blood  diseases.  It  is 
said  occasionally  to  occur  in  scarlatina,  and  erysipelas  may  induce  it. 
Abercrombie  has  referred  to  an  epidemic  of  the  latter  distemper  which 
occurred  amongst  the  children  in  the  Merchants'  HosiDital  in  Edinburgh 
in  the  yeai- 1824.  The  disease  was  of  a  mild  tyj)e,  but  two  of  the  children 
rapidly  died,  and  on  examination  pus  was  discovered  in  the  abdominal 
cavity.  Peritoneal  inflammation  is  also  common  as  a  consequence  of 
abdominal  tuberculosis,  but  the  subject  of  tubercular  peritonitis  will  be 
considered  separately. 

Besides  occurring  as  a  result  of  the  above  causes,  peritonitis  may  arise 
as  a  primary  disease  in  a  child  in  whom  no  deviation  from  health  has 
been  noticed.  It  is  sometimes  seen  in  school-children  of  either  sex,  and 
has  been  attributed  by  Gauderon  to  chilling  of  the  surface  after  violent 
exercise,  and  by  Legrand  to  lying  prone  upon  the  damp  earth. 

3Iorhid  Anatomy. — The  pathological  characters  of  peritonitis  are  the 
same  in  the  child  as  in  the  adult.  The  vessels  are  injected,  and  the 
normal  polish  of  the  serous  surfaces  is  lost,  owing  to  inflammatory  exuda- 
tion. There  is  infiltration  and  thickening  of  the  sub-serous  tissue,  with 
proUfe ration  of  cells  in  the  epithelial  covering  of  the  membrane.  The 
exudation  poured  out  from  the  distended  capillaries  coagulates  on  the 
surface  and  forms  a  false  membrane,  which  is  at  first  thin  and  gTayish  in 
colour,  afterwards  thicker  and  yellow.  It  causes  adhesion  between  neigh- 
bouring organs,  and  glues  the  coils  of  intestine  to  one  another.  There  is 
besides  effusion  into  the  abdominal  cavity.  Its  quantity  varies.  Some- 
times it  is  copious.  The  fluid  is  usually  opalescent,  from  proliferated 
epithelial  cells,  or  may  be  distinctly  purulent. 

The  longer  the  disease  continues,  the  tougher  and  thicker  the  exuda- 
tion becomes,  so  that  it  may  form  bands  which  pass  from  one  organ  to 
another,  and  in  long-standing  cases  may  constrict  portions  of  the  bowel 
and  cause  serious  consequences.  If  the  patient  survive,  the  fluid  becomes 
absorbed,  and  the  exudation  gets  tougher  and  forms  firm  adhesions  be- 
tween neighbouring  parts,  as  well  as  opaque  fibrous  patches  upon  the 
surface  of  organs,  more  or  less  thick  and  hard.  When  the  peritonitis  is  at 
first  partial,  as  may  happen  when  the  inflammation  is  due  to  perforation 
of  the  bowel,  the  exudations  and  consequent  adhesions  ma}^  confine  the 
extravasated  matters  within  certain  limits,  and  thus  locahse*the  inflamma- 
tion. 

Pent-up  collections  of  matter  may  also  arise  in  the  following  manner  : 
On  account  of  gravitation  the  purulent  fluid  is  ajDt  to  collect  in  certain 
spots,  especially  above  and  behind  the  liver.  If  the  child  do  not  die,  the 
fluid,  thus  accumulated,  may  become  shut  off  by  adhesions  so  as  to  pro- 
duce a  local  abscess.  Abscesses  arising  in  this  way  are  usually  seated 
near  the  diaphragm,  often  between  that  muscle  and  the  liver  or  spleen. 
Such  a  collection  of  matter  may  eventually  open  into  the  chest  and  set  up 
pneumothorax. 

Symptoms. — In  the  child  peritonitis  may  give  rise  to  violent  and  acute 
symptoms,  as  it  does  in  the  adult.  As  a  rule,  it  is  the  primary  form — 
essential  peritonitis,  as  it  has  been  called — which  is  accompanied  by  these 
signs  of  serious  disease.  Also,  when  the  inflammation  follows  upon  a  blow 
or  other  external  injury  in  a  child  previously  in  good  health,  the  symj)toms 
are  usually  striking  and  severe.  Iii  the  secondary  form,  when  the  child  is 
already  reduced  by  illness,  the  symptoms,  although  often  sufficiently  pro- 


ACUTE   PEEITONITIS — SYMPTOMS.  687 

nounced,  may  yet  be  to  a  certain  extent  masked  by  tlae  state  of  profound 
collapse  into  which  the  patient  is  thrown.  In  other  cases  the  disease  may 
be  more  or  less  latent,  and  indeed  is  sometimes  not  discovered  until  the 
body  is  subjected  to  examination  in  the  dead-house. 

In  the  severe  primary  form  the  child  complains,  often  quite  suddenly, 
of  pain  in  some  part  of  his  belly — in  either  flank,  above  the  pubes,  or  about 
the  navel.  At  first  comparatively  slight,  the  pain  soon  gets  more  severe 
and  general,  and  at  the  same  time  the  belly  becomes  tender.  Vomiting  is 
almost  always  an  early  symptom.  The  child  first  ejects  partially  digested 
food,  and  then  glairy  and  bilious  matters.  If  the  eftbrts  to  vomit  are  vio- 
lent, they  occasion  great  distress,  on  account  of  the  pain  and  tenderness  of 
the  belly  ;  and  after  each  effort  the  child  lies  back  with  haggard,  pale  face, 
beads  of  sweat  standing  upon  his  bro^v.  Fever  is  present  from  the  begin- 
ning, and  may  be  preceded  by  a  sense  of  chilliness,  or  even  distinct  rigors. 
The  degree  to  which  the  temperature  rises  varies,  as  it  does  in  inflamma- 
tion of  the  other  serous  membranes  in  the  child.  Sometimes  it  may  reach 
104'^,  or  even  higher,  but  at  other  times  it  remains  little  over  100°.  The 
average  degree  of  pyrexia  is  perhaps  between  101°  and  102^.  At  night  the 
<;hild  is  restless  and  sleeps  little,  often  waking  up  and  crying  with  pain  in 
liis  belly.     Sometimes  he  is  disturbed  by  delirious  fancies  and  talks  wildly. 

Almost  from  the  first  the  child  is  unwilling  to  move,  and  he  soon  takes 
to  his  bed.  There  he  lies  upon  his  back,  or  inclining  to  one  side,  with  legs 
and  thighs  flexed.  His  face  is  pale  and  distressed,  his  nose  looks  sharp, 
and  the  nostrils  are  thin  and  expanded.  The  slightest  touch  upon  the  belly 
is  painful,  and  he  seems  to  dread  the  least  movement.  If  the  coat  of 
the  bladder  is  involved,  there  is  retention  of  urine.  If  the  peritoneal 
coat  of  the  bowel  is  inflamed,  attacks  of  the  most  violent  colic  may  come  on 
at  intervals,  and  throw  the  child  into  an  agony  of  pain.  On  examination 
of  the  beUy,  this  is  seen  to  be  distended  with  gas ;  it  is  motionless  in  res- 
piration ;  there  is  some  tension  of  the  parietes,  and  the  tenderness  is  exces- 
sive. Gentle  j)ercussion  elicits  a  tympanitic  sound  over  the  anterior  re- 
gions ;  but  in  the  depending  parts,  where  the  fluid  collects,  the  note  is  dull. 
Sometimes  the  fluid  is  suf&cient  in  quantity,  and  sufficiently  free,  to  give  a 
distinct  sense  of  fluctuation  ;  but  the  absence  of  free  fluctuation  is  no  sign 
of  the  absence  of  fluid.  There  is  often  effusion  between  the  coils  of  intes- 
tine and  in  the  meshes  of  the  exuded  lymph  ;  but  this  transmits  the  wave 
of  fluid  very  imperfectly  -f^cm  one  side  of  the  belly  to  the  other.  As  a 
general  rule,  perhaps,  fluctuation  is  imperfect  or  absent.  In  these  cases 
Duparcque  has  suggested  that  the  child  should  be  placed  on  his  side  for  a 
few  minutes.  The  whole  quantity  of  fluid  will  then  gravitate  to  the  flank 
on  the  depending  side.  If  the  child  be  then  quickly  turned  upon  his  back, 
dulness  and  fluctuation  will  be  found  at  first  at  the  site  of  the  accumulated 
fluid,  but  owing  to  the  second  change  of  position  will  quickly  disappear. 

If  the  distention  of  the  abdomen  become  great,  it  may  cause  serious 
distress  by  compressing  the  lungs  and  displacing  the  heart.  In  such  cases 
there  is  dyspnoea,  with  some  lividity  of  the  face,  and  hurry  of  breathing. 
The  tongue  is  furred  on  the  dorsum,  red  at  the  tip  and  edges.  The  pulse 
is  small,  hard  and  frequent.  The  urine  is  high  coloured,  but  not  espe- 
cially acid,  and  its  passage  causes  no  pain.  The  bowels  are  confined  or  re- 
laxed. Constipation  is  the  rule  in  adults,  but  in  children  it  is  common  to 
find  looseness  of  the  bowels  with  watery  and  offensive  stools.  Still,  even  in 
the  child,  if  the  muscular  coat  of  the  bowel  be  involved,  and  there  be  no 
sub-mucous  oedema  to  cause  effusion  into  the  intestinal  tube,  the  bowels 
may  be  obstinately  confined. 


DISEASE   ITiT    CHILDEEISr.     ' 

As  tlie  illness  progresses  tlie  vomiting  usually  ceases,  but  the  other 
symptoms  become  more  and  more  severe.  The  tympanitis  increases ;  the 
tongue  becomes  dry  and  brown  ;  the  eyes  are  sunken  ;  the  face  is  haggard 
and  pale,  often  cyanotic.  The  child  lies  with  his  eyes  half  closed  in  a  dreamy 
state.  His  pulse  is  excessively  small  and  rapid ;  and  death  usually  occurs 
by  the  end  of  the  week. 

In  exceptional  cases  the  disease  ends  in  recovery,  the  fluid  being  ab- 
sorbed or  discharged  through  the  navel  or  abdominal  wall.  I  have  met 
with  one  case  in  which  purulent  matter  escaped  in  large  quantity  through 
the  umbihcus,  and  the  child  recovered.  If  the  pus  be  evacuated  by  this 
channel,  the  relief  exjoerienced  by  the  patient  is  usually  extreme.  The  vol- 
ume of  the  belly  is  diminished ;  vomiting,  if  it  had  persisted,  ceases ;  the 
tongue  begins  to  clean,  and  some  sigriig  of  returning  appetite  are  manifested. 
M.  Gauderon  has  referred  to  ten  such  cases,  in  eight  of  which  recovery  took 
place.  The  fistula  left  after  the  discharge  of  the  purulent  matter  closes  in 
about  a  month,  sometimes  at  an  earlier  date.  The  disease  is  said  some- 
times to  pass  into  a  chi-onic  state.  Such  a  termination  would  excite  sus- 
picions of  a  tubercular  origin  for  the  jDciitonitis.  There  are  few  recorded 
cases  of  chronic  peritonitis  in  the  child,  where  an  opportunity  of  examining 
the  body  was  afforded,  which  do  not  make  mention  of  tubercle  ia  the  ab- 
dominal cavity  or  in  the  lungs. 

When  the  peritonitis  is  the  result  of  perforation  of  the  bowel,  the  oc- 
currence of  this  serious  accident  is  indicated  by  sudden  severe  pain  in  the 
belly,  which  becomes  distended  with  gas  and  excessively  tend-er.  At  the 
same  time  the  child  is  reduced  by  the  shock  to  a  state  of  collapse.  His 
face  is  haggard  and  ghastly  looking  ;  his  eyes  are  deeply  sunken  ;  his  pulse 
becomes  very  quick  and  small ;  his  breathing  is  thoracic  ;  his  hands  and 
feet  are  cold,  but  the  temperatui-e  of  the  bod}-,  if  taken  in  the  rectum,  is 
found  to  be  103°,  104°,  or  even  higher.  Sometimes  he  vomits,  and  the 
secretion  of  mine  is  suppressed.  On  examination  of  the  belly  it  is  foimd 
that  the  liver  dulness  has  disappeared.  Xiemeyer  gives  this  as  a  certain 
sign  that  peritonitis  resulting  fi'om  perforation  of  the  bowel  has  taken  place. 

The  above  is  the  t^^Dical  form  ;  but  often  the  symptoms  are  much  less 
characteristic.  Pain  and  tenderness  may  be  little  complained  of,  and,  as 
Andral  has  pointed  out,  sudden  increase  of  the  prostration  and  the  ghastly 
look  of  the  face  may  be  the  only  symptoms  drawing  attention  to  this  new 
compUcation.  Even  w^hen  the  pain  has  been  severe,  it  often  ceases  com- 
pletely for  some  hours  before  death.  In  most  cases  the  child  survives 
perforation  but  a  very  few  days.  Sometimes,  if  adhesion  have  previously 
taken  place  in  the  neighbourhood  of  the  ulcer,  so  as  to  confine  the  extra- 
vasated  matters  to  the  immediate  vicinity  of  the  ruptui-e,  the  peritonitis 
may  be  locahsed.  An  abscess  then  forms,  which  after  a  time  makes  its 
way  to  some  point  of  the  sui'face,  and  discharges  its  contents  externally. 
Under  these  more  favom-able  conditions. the  child  may  recover,  but  it  is 
needless  to  say  that  such  cases  are  exceptional. 

Sometimes  peritonitis  in  the  child  is  entirely  latent,  and  is  only  dis- 
covered on  post-mortem  examination  of  the  body.  In  such  cases  the 
belly  may  be  swollen,  and  the  child  may  look  ill  and  colourless  ;  but  pain 
may  not  be  complained  of  ;  there  may  be  no  tenderness  of  the  abdomen, 
no  tension  of  the  parietes,  no  fluctuation,  or  other  sign  to  indicate  the 
presence  of  this  serious  lesion.  I  have  only  obseiwed  this  latent  form  in 
cases  of  secondary  peritonitis.  In  the  httle  boy,  whose  case  has  been  be- 
fore referred  to,  where  peritonitis  resulted  from  extension  of  the  puinolent 
inflammation  to  the  beUy  from  the  chest,  the  abdomen  was  swollen,  and  a 


ACUTE   PEEITOIs^ITIS — SYMPTOMS — DIAGNOSIS.  689 

watery  diarrhoea  began  wbicli  resisted  all  treatment ;  bnt  there  appeared 
to  be  no  pain  or  tenderness  ;  the  parietes  were  soft  and  flaccid  ;  no  fluc- 
tuation could  be  detected  ;  and  although  on  account  of  its  fulness  the  ab- 
domen was  repeatedly  examined,  nothing  was  discovered  to  lead  to  the 
suspicion  of  the  existence  of  peritonitis.  On  examination  of  the  body 
some  purulent  fluid  was  discovered  in  the  peritoneal  cavity,  and  the  bowels 
were  moi'e  or  less  adherent  fi'om  exuded  lymph.  It  is  important  to  be 
aware  of  the  occasional  latency  of  the  inflammation,  so  that  we  may  not 
exclude  peritonitis,  because  the  symptoms  and  signs  are  ill  marked  and 
httle  characteristic  of  the  lesion.  If  in  such  a  case  the  delirium,  restless- 
ness, and  tendency  to  stupor  are  unusually  prominent,  the  most  experienced 
physician  may  misapprehend  the  nature  of  the  illness  and  be  disposed  to 
suspect  the  onset  of  a  meningitis.  Duparcque  relates  a  case  in  wjiich  this 
mistake  was  actually  made,  and  the  error  was  only  discovered  on  examina- 
tion of  the  body. 

Diagnosis. — When  the  symptoms  are  well  marked  the  diagnosis  of  the 
disease  is  easy.  Swelling  of  the  belly,  which  takes  no  part  in  the  respiratory 
movement  and  is  intensely  painful  and  tender  ;  vomiting  ;  a  pale  haggard 
face,  and  a  quick  wiry  pulse — these,  together  with  the  position  of  the  child 
in  his  bed,  with  the  thighs  flexed,  and  his  dread  of  movement  or  even  of  a 
touch,  form  a  verj'  characteristic  gToup  of  symptoms. 

When  the  inflammation  is  a  consequence  of  pei'f oration  of  the  bowel, 
the  comphcation  is  sufiiciently  clear.  Even  if  the  pain  and  tenderness  are 
inconsiderable,  the  sudden  occurrence  of  collapse  with  tympanitis  suffi- 
ciently indicates  what  has  occuiTcd. 

From  tuberculous  jieritonitis  the  acute  simple  form  may  be  readily 
distinguished  by  the  more  violent  character  of  the  symptoms  and  the 
more  rapid  course  of  the  disease.  In  the  tuberculous  variety  vomiting  is 
rare,  and  the  illness  rans,  as  a  rule,  a  very  slow  and  chi'onic  course. 

In  cohc  there  is  often  constipation  and  vomiting,  with  severe  par- 
oxysmal pain  in  the  belly  ;  but  between  the  attacks  of  pain  there  is  no 
tenderness  ;  the  pulse  is  less  rapid,  small,  and  wiiy,  and  there  is  none  of 
the  fear  of  movement  which  is  so  characteristic  of  peritonitis. 

Rheumatism  of  the  abdominal  wall  may  be  mistaken  for  inflammation 
of  the  peritoneum.  The  distinctive  characters  are  given  elsewhere  (see 
page  159). 

It  is  important  to  remember  the  occasional  latency  of  the  symptoms  in 
peritonitis.  Tension  of  the  abdominal  parietes  on  palp5,tion,  especially 
if  partial,  in  a  child  above  the  age  of  infancy,  must  not  be  disregarded. 
It  may,  of  course,  be  voluntary,  and  the  belly  be  quite  healthy  ;  but  if  the 
abdomen  is  full,  and  the  child  looks  ill,  with  a  haggard,  pinched  face,  we 
should  consider  the  possibihty  of  peritonitis,  and  make  a  very  careful  ex- 
amination. In  cases  of  chi'onic  empyema  we  should  be  always  on  the 
watch  for  the  occurrence  of  peritonitis.  If  the  child,  after  a  period  of  im- 
jDrovement,  cease  all  at  once  to  gain  gi'ound  and  begin  to  look  pale  and 
distressed,  with  an  elevated  temperatiu'e,  a  more  or  less  distended  belly, 
and  a  rapid,  wiiy  pulse,  we  are  justified  in  suspecting  peritonitis  although 
there  be  no  tension,  tenderness,  or  other  sign  connected  with  the  abdo- 
men to  give  suppori  to  this  opinion. 

It  is  well  in  aU  cases  where  a  feverish  child  looks  ill  and  has  a  dis- 
tended belly,  to  make  trial  of  Duparcque's  plan  of  placing  the  patient  for- 
a  minute  or  two  on  his  side,  so  as  to  allow  all  the  j)eritoneal  fluid  to  collect 
in  the  depending  flank.  Turning  him,  then,  quickly  upon  his  back,  eridences. 
of  fluid,  if  peritonitis  be  present,  will  be  found  at  the  site  of  accumulation. 
44 


690  DISEASE   11^   CHILDREJS". 

Had  this  been  done  in  the  case  of  the  little  boy  already  twice  referred  to, 
the  cause  of  the  distention  of  the  abdomen  would  not  have  escaj)ed  re- 
cognition. 

When  the  inflammation  affects  exclusively  the  visceral  peritoneum,  the 
musculai'  coat  of  the  bowel  is  usually  impHcated.  There  is  then  often 
obstinate  constipation  from  paralysis  of  the  affected  portion  of  the  intes- 
tine ;  there  may  be  vomiting  ;  and  excessive  tenderness  of  the  belly  is 
combined  with  paroxysms  of  colicky  pain  of  agonizing  severity.  Such  cases 
may  simulate  very  closely  obstruction  of  the  bowels,  and  may  be  mistaken 
for  intussusception.  Some  time  ago  I  saw,  with  Mr.  Izod,  of  Esher,  a  young 
lady,  aged  ten  j^ears,  who  had  got  up  in  her  usual  health  on  the  morning 
of  the  previous  Sunday.  In  the  afternoon  of  that  day,  after  running  about 
in  the  garden  (the  day  was  very  damp)  she  complained  suddenly  of  jDain 
in  the  belly.  That  night  she  slept  fairly  well,  but  comjolained  of  -pedn. 
again  on  the  next  (Monday)  morning.  A  pill  was  given  to  her,  followed 
by  a  sahne. 

This  acted  on  the  bowels,  but  the  pain  was  not  reheved.  She  slept 
badly  that  night.  On  the  Tuesday  morning  she  was  seen  by  jMr.  Izod, 
who  found  a  temperatui-e  of  102°.  There  was  some  tenderness  of  the 
belly,  with  frequent  paroxysms  of  colicky  pain.  She  had  had  no  vomiting. 
Opium  was  given,  but  the  pains  continued,  becoming  more  and  more  fre- 
quent and  more  and  more  severe.  The  bowels  were  confined  all  the  week 
except  on  the  Thursday,  when  they  acted  spontaneously  twice,  the  stools 
being  copious  and  lumjoy,  light  coloured  and  rather  offensive.  I  saw  the 
child,  with  ]\Ii'.  Izod,  on  the  following  Sunday — the  eighth  day.  She  was 
lying  in  bed  hollow-eyed  and  livid.  Every  ten  minutes  a  paroxysm  of 
pain  came  on,  dui-ing  which  she  raised  herself  up  in  an  agony  and  tried 
to  get  on  to  the  floor.  The  belly  was  swollen  and  excessively  tender,  the 
slightest  touch  appearing  to  induce  a  fi'esh  access  of  pain.  The  child  had 
been  kept  for  some  time  under  the  influence  of  chloroform,  but  when  the 
anaesthetic  was  remitted  the  pain  instantly  retiu-ned.  Hj-jDodermic  in- 
jections of  morphia  and  atropine  were  given  repeatedly  ;  but  large  quan- 
tities of  these  nai-cotics  apjDcared  to  dull  the  pain  but  shghtly.  The  child 
died  on  the  following  day. 

On  examination  of  the  body  the  smaU  intestine  was  found  healthy,  ex- 
cept for  a  reddened  and  ulcerated  patch  in  the  middle  of  the  jejunum. 
The  lai'ge  bowel  was  distended  with  hquid  fgeces.  Its  parietal  coat  was 
very  red  and  inflamed,  but  there  was  no  injection  of  its  mucous  hning. 
The  parietal  peritoneum  was  not  inflamed.  Its  cavity  contained  much 
dirty  serum,  but  no  lymj)h. 

If  the  inflammation,  instead  of  being  confined  to  the  visceral  perito- 
neum, spreads  through  the  muscular  coat  to  the  mucous  membrane  (phleg- 
monous enteritis)  there  is,  in  addition  to  the  above  symptoms,  a  profuse  wa- 
tei-y  diarrhoea.  The  diagnosis  is  then  easy.  If  the  mucous  membrane  is  not 
implicated,  there  is  constipation  which  may  be  obstinate.  In  such  a  case 
intussusception  may  be  excluded  by  noticing  the  early  occToi'rence  of  ten- 
derness, of  abnormal  tension  of  the  abdominal  wall,  and  in  most  cases  of 
fever.  Moreover,  there  is  no  tenesmus  ;  and  the  passage  of  blood  and 
bloody  mucus  from  the  bowel,  which  is  such  a  characteristic  feature  of 
intussusception,  is  absent.  If,  as  in  the  case  just  narrated,  an  action  of 
the  bowels,  spontaneous  or  otherwise,  occurs  some  days  after  the  be- 
ginning of  the  illness,  there  is  evidently  no  comj^lete  obstruction  of  the 
intestinal  channel ;  but  unless  the  invaginated  portion  of  gut  be  tightly 
constricted,  secondary  peritonitis  is  very  unlikely  to  arise. 


ACUTE   PEEITOlSriTIS — PROG]N"OSIS — TREATMETSTT.  691 

Prognostic. — The  disease  is  fatal  in  the  large  majority  of  cases.  In 
primary  peritonitis  from  cold  the  chances  are  perhaps  a  trifle  less  unfa- 
voiirable  than  in  the  other  varieties.  Eestlessness  and  inability  to  sleep 
are  bad  signs.  In  partial  peritonitis,  if  the  inflammation  remain  localised, 
the  child  will  sometimes  recover. 

Treatment. — Directly  the  existence  of  peritonitis  is  ascertained  no  time 
should  be  lost  in  resorting  to  enei'getic  measures  for  its  removal.  The 
most  perfect  quiet  in  bed  should  be  enforced,  and  the  presence  of  too 
many  attendants  should  be  strictly  forbidden.  One  good  nurse  can  do  all 
that  is  required.  Turj^entiue  stupes  should  be  applied  to  the  belly,  and 
opium  should  be  given  by  the  mouth  or  by  hypodermic  injection.  For  a 
child  ten  years  of  age  six  or  eight  drops  of  laudanum  may  be  given  in  a 
teaspoonful  of  water  every  four  hours,  or  one-twelfth  of  a  grain  of  morphia 
may  be  injected  under  the  skin,  and  the  operation  can  be  repeated  as  re- 
quired. It  is  best  to  produce  drowsiness,  with  some  contraction  of  the 
pupil.  Children  vary  gTcatly  in  their  susceptibility  to  this  form  of  nar- 
cotic ;  but  inflammation  of  the  peritoneum,  if  the  pain  is  great,  may  require 
larger  quantities  of  the  drug  than  one  would  be  disposed  to  anticipate  to 
produce  a  sufficiently  sedative  effect  upon  the  patient.  Thus,  I  have  known 
a  httle  infant  of  four  months  old,  who  was  sufl:ering  from  agonising  colic, 
owing  to  inflammation  of  the  peritoneal  coat  of  the  bowels,  take  three 
minims  and  a  quarter  of  laudanum  in  the  space  of  two  hours,  with  but 
Httle  remission  of  his  suffering.  The  same  infant  some  hours  afterwards 
had  a  hypodermic  injection  of  one-twelfth  of  a  grain  of  morphia  ;  and  this 
powerful  dose,  although  it  contracted  the  pupils  to  the  size  of  a  join's  point, 
did  not  completely  suppress  all  signs  of  pain.  Energetic  counter-irri- 
tation is  of  great  value  in  these,  cases,  and  when  the  turjoentine  ca,n  no 
longer  be  endured  upon  the  abdomen,  it  may  be  applied  to  the  front  of  the 
chest  or  to  the  back.  Cold  ajDphcations  are  well  borne  in  many  cases,  and 
seem  sometimes  to  comfort  more  than  hot  flannels.  Cold  is  employed  by 
means  of  cloths  wrung  out  of  ice-cold  water  and  frequently  changed. 

All  purgatives  are  to  be  avoided.  If  it  be  considei'ed  necessary  to  re- 
lieve the  bowels,  this  can  be  done  by  enema.  If  the  peritoneal  coat  of  the 
intestine  is  involved,  constipation  is  often  absolute  ;  but  it  is  best  to  make 
no  attempt  to  excite  a  movement.  Our  object  is  to  quiet  peristaltic  action 
and  insure  rest.  Probably  the  chief  value  of  opium  consists  in  its  in- 
fluence in  this  du'ection.  Any  attempt,  therefore,  to  oppose  its  action 
will  be  hurtful.  If  in  these  cases  the  paroxysms  of  pain  are  frequent  and 
agonising,  it  is  advisable  in  a  robust  subject  to  apply  leeches  freely  to  the 
abdomen.  I  believe  this  form  of  disease  to  be  one  in  which  the  abstrac- 
tion of  blood  is  a  distinctly  valuable  therapeutic  means ;  and  should  not 
hesitate  to  employ  ten  or  twelve  leeches,  or  even  more,  if  the  attacks  of 
colicky  pain  resisted  the  action  of  morphia.  Even  when  the  inflammation 
is  limited  to  the  parietal  peritoneum,  leeches  may  be  employed  in  the  case 
of  a  sturdy  child,  when  the  disease  is  primary,  especially  if  the  pain  and 
tenderness  can  be  referred  to  any  particular  spot.  In  many  severe  cases 
of  peritoneal  enteritis,  where  the  pain  is  excessive,  and  morphia,  even  fol- 
lowing the  ajophcation  of  leeches,  proves  imiDotent  to  control  the  paroxysms 
of  suffering,  it  is  advisable  to  keejo  the  child  under  the  influence  of  chloro- 
form. 

If  thirst  be  much  complained  of,  it  is  best  allayed  by  sucking  ice  ;  and 
the  same  measure  is  also  useful  in  checking  the  tendency  to  vomit.  The  food 
should  be  concentrated.  Strong  beef-essence,  milk  in  small  quantities  at 
a  time,  and  yolk  of  egg  can  be  given  ;  and  as  the  patient  becomes  weaker. 


692  DISEASE  iisr  children. 

a  teaspoonful  of  sound  brandy  in  milk  or  water  should  be  administered 
every  few  hours. 

Tympanitis  is  a  symptom  which  it  is  difficult  to  treat  successfully.  I 
have  never  seen  benefit  result  from  enemata  of  assafoetida  or  the  passage 
of  a  long  tube  into  the  bowel.  It  is  best  relieved  by  free  stimulation,  and 
the  external  application  of  turpentine.  If  the  child  survive,  and  the 
abdominal  distention  continue  after  the  inflammation  has  begun  to  sub- 
side, as  a  consequence  of  loss  of  tone  in  the  bowel,  gentle  frictions  to  the 
belly,  compression  with  a  flannel  bandage,  and  quinine  and  strychnia  by 
the  mouth  are  of  service. 

"When  peritonitis  is  the  result  of  perforation  of  the  bowel,  warmth  to 
the  abdomen  and  the  feet,  the  free  use  of  opium,  concentrated  food,  and 
energetic  stimulation  offer  the  best  chances  of  success. 

In  every  case  where  collections  of  matter  can  be  discovered  under  the 
skin,  either  at  the  umbilicus  or  elsewhere,  no  time  should  be  lost  in  aiding 
the  escape  of  the  pus  by  the  punctm-e  of  a  lancet. 


CHAPTER  XIII. 

TUBERCULAE,  PERITONITIS. 

The  inflammation  of  tlie  peritoneum  which,  results  from  abdominal  tuber- 
culosis usually  runs  a  subacute  or  chronic  course.  The  disease  is  rarely 
acute  ;  but  it  is  important  to  be  aware  that  an  acute  form  is  occasionally 
met  with,  and  is  very  difficult  to  detect.  Tubercular  peritonitis  may  be 
the  only  indication  of  the  tubercular  disease  to  be  discovered  in  the  body, 
or  may  be  accompanied  by  signs  of  distress  from  other  parts  of  the  system. 
It  is  rarely  seen  in  young  children,  perhaps  never  in  infants,  and  does  not 
begin  to  be  a  common  affection  before  the  seventh  or  eighth  year  of  Hfe. 
After  that  age,  however,  it  is  frequently  met  with.  The  earliest  age  at 
which  the  disease  has  come  under  my  notice  has  been  three  years. 

Morbid  Anatomy. — On  opening  the  abdomen  in  a  case  of  tubercular 
peritonitis  we  find  the  bowels  covered  more  or  less  completely  with  yellow- 
ish, greenish,  or  gray  coloured  lymph.  The  consistence  of  this  varies. 
It  may  be  loose  and  soft  in  texture,  or  tough.  Usually  it  is  mixed  up 
with  thick  cheesy  matter.  The  lymph  often  lines  the  parietal  peritoneum, 
and  penetrates  between  the  coils  of  intestine,  which  it  glues  firmly  together. 
■Sometimes  the  whole  bowel  is  so  matted  together  into  a  confused  mass 
that  it  is  quite  impossible  to  follow  out  the  course  of  the  canal.  More  or 
less  greenish  or  yellow  piu'ulent  matter  is  held  in  the  meshes  of  the  exuded 
lymph,  and  more  is  seen  to  have  gravitated  to  the  deeper  parts  of  the 
abdominal  cavity.  On  clearing  away  the  lymph  from  the  surface  of  the 
peritoneum  and  contained  organs,  we  find  gray  and  yellow  granulations 
studding  the  surface  more  or  less  thickly.  With  these  are  larger  masses 
and  even  broad  plates  of  cheesy  matter,  probably  also  tubercular  in  their 
nature.  These  are  yellow  or  fawn  coloured,  and  may  be  dotted  with 
black  points  of  pigment.  Similar  cheesy  masses  may  be  discovered  lying 
in  the  adhesions  formed  by  one  organ  with  another — between  the  liver  or 
the  stomach  and  the  diaphragm,  and  between  the  coils  of  intestine.  The 
more  chronic  the  case  the  larger  and  thicker  are  the  caseous  masses. 
When  the  case  is  acute,  these  are  usually  absent ;  but  the  serous  surface 
is  covered  with  lymph  in  the  substance  of  which  are  scattered  gray  and 
yellow  granulations  varying  in  size  from  a  jDin's  head  to  a  pea. 

The  larger  tubercular  cheesy  masses  may  cause  the  intestinal  wall  to 
give  way,  perforated  from  without.  Extravasation  of  the  contents  of  the 
intestine  rarely  takes  place  into  the  peritoneal  cavity,  owing  to  the  existence 
of  the  firm  adhesions ;  but  in  this  way  a  new  and  unnatural  communication 
may  be  formed  either  between  two  diflerent  parts  of  the  intestinal  tube,  as 
was  noticed  by  Messrs.  Killiet  and  Barthez,  or  between  the  bowel  and  the 
umbilicus,  as  happened  in  a  case  recorded  by  Henoch. 

In  the  most  chronic  cases  the  adhesions  may  be  very  tough  and  fibrous, 
and  even  the  lymph  on  the  peritoneal  surface  may  resemble  connective 
tissue.     The  omentum,   itself  unusually  firm  in  its  texture,  may  be  ad- 


694  DISEASE   I?f    CHILDKEX. 

herent  to  the  abdominal  wall ;  and  the  mesentery  may  be  tough  and  con- 
tracted. 

Tubercular  peritonitis  is  not  always  general.  Sometimes  it  is  partial^ 
and  is  then  usually  confined  to  the  upper  parts  of  the  abdominal  cavity — 
the  neighbourhood  of  the  diaphragm,  the  liver,  and  the  spleen.  The  liver 
itself  is  often  enlarged  from  amyloid  or  fatty  change,  and  has  been  found 
by  some  observers  to  be  cirrhotic.  The  bowels  are  often  the  seat  of  tuber- 
cular ulceration,  and  the  mesenteric  glands  are  enlarged  and  cheesy. 

Besides  the  peritoneum,  tubercle  is  often  found  in  other  organs.  In 
the  more  chronic  cases  it  may  be  limited  to  the  abdomen  ;  but  in  the 
acute  form  the  abdominal  disease  is  almost  invariably  a  part  of  a  general 
development  of  tubercle  over  the  body. 

Symptoms. — Tubercular  peritonitis  always  begins  insidiously,  and  its 
symptoms  may  be  far  from  being  well  marked.  In  some  cases  attention 
is  diverted  'from  the  belly  by  the  more  striking  phenomena  arising  from 
tubercle,  and  the  consequences  it  involves,  in  other  organs  ;  but  even  if 
the  tubercular  granulations  are  limited  to  the  abdomen,  the  early  symp- 
toms are  often  curiously  insignificant  when  we  consider  the  serious  nature 
of  the  disease.  In  these  cases  of  local  tuberculosis  the  general  nutrition 
may  be  good  at  first,  and  the  appearance  of  the  patient  fairly  robust ;  but 
as  the  illness  progresses  the  child  rapidly  loses  flesh,  colour,  and  strength, 
and  before  death  occui-s  may  reach  an  extreme  degree  of  emaciation. 

In  an  ordinary  case,  the  first  sign  noticed  by  the  mother  is  that  the 
child's  belly  looks  large,  and  the  next,  that  it  is  a  little  tender.  The  child 
is  unusually  listless  and  dull.  He  looks  iU.  He  avoids  exercises  which 
cause  a  jolt  or  jar  to  his  body,  and  shows  a  caution  in  all  his  movements 
which  soon  attracts  attention. 

A  boy  between  ten  and  eleven  years  old  was  brought  to  me  at  the  hos- 
pital. The  lad  had  always  been  healthy  and  active,  although  there  was  a 
tendency  to  consumption  in  his  family.  For  some  weeks  it  had  been 
noticed  that  he  looked  pale,  often  complained  of  nausea  after  food,  was 
languid,  lay  about  instead  of  playing,  and  cried  if  he  was  scolded.  Then 
he  began  to  suffer  from  pains  in  his  abdomen,  and  excused  himself  on  this 
account  from  running  errands  as  he  had  been  accustomed  to  do.  Pressure 
on  the  belly,  as  in  leaning  against  a  chair  or  table,  had  not  been  noticed  to 
be  painful ;  but  the  boy  said,  that  if  he  leaned  forward  his  "food  "  rose  at 
once.  After  some  days  the  abdomen  began  to  be  tender  and  painful.  The 
child  complained  of  feehng  cold,  and  slept  badly  at  night.  He  was  thirsty, 
but  cared  little  for  food.     The  bowels  were  relaxed. 

The  above  is  a  very  good  illustration  of  the  mildness  of  the  early 
symptoms,  and  the  stealthy  way  in  which  the  disease  creeps  on.  The  ab- 
dominal pains  appear  to  be  at  first  intermittent  and  of  a  griping  character. 
The  bowels  are  relaxed  or  confined.  Often  the  disease  is  said  to  have 
begun  with  diarrhoea,  and  the  attacks  of  looseness  are  sometimes  separated 
by  periods  of  more  or  less  marked  constipation.  Nausea  and  vomiting  are 
not  such  common  symptoms  in  this  form  of  peritonitis  as  the}''  are  in  the 
simple  variety,  and  the  appetite  may  be  preserved  for  a  considerable  time. 

After  some  weeks  the  tenderness  of  the  abdomen  and  its  sensitiveness- 
to  the  slightest  jar  or  shock,  as  well  as  the  increasing  weakness  of  the 
patient,  obliges  him  to  keep  his  bed.  But  he  will  sometimes  go  about  as- 
usual,  if  allowed  to  do  so,  for  a  long  time — long  after  the  disease  is  fully 
established.  He  may  then  be  noticed  to  take  very  characteristic  precau- 
tions to  avoid  jolting  his  belly  when  he  moves.  Thus,  he  will  steady  it 
with  his  hand  as  he  walks  ;  and  go  backwards  down-stairs,  so  that  he  may 


TUBEKCULAE   PEEITONITIS — SYMPTOMS.  695 

more  conveniently  pass  from  step  to  step  upon  Lis  toes.  If  tlie  tempera- 
tui-e  be  taken  at  this  time,  it  will  be  found  to  be  higher  than  normal ;  but 
the  mercury  seldom  rises  above  101°  in  the  evening.'  In  the  morning  it 
may  be  at  the  natural  level. 

If  the  belly  is  examined,  it  will  be  found  to  be  distended  and  oval  in  shape, 
the  projection  being  more  marked  about  the  umbiliciTS  and  epigastrium 
than  below  the  navel.  The  skin  has  often  a  shiny  look  ;  the  veins  ramify- 
ing over  the  surface  may  be  noticed  to  be  full ;  and  the  natural  markings 
of  the  belly  have  disappeared.  On  palpation  there  is  often  increased  ten- 
sion of  the  recti  muscles,  which  contract  instinctively  to  protect  the  tender 
peritoneum,  and  the  resistance  offered  by  the  contents  of  the  abdomen  is 
very  unequal.  Li  some  parts  the  parietes  are  easily  depressed  ;  in  others 
a  certain  feeling  of  solidity  is  conveyed  to  the  finger,  and  distinct,  firm 
masses  may  be  often  detected  here  and  there.  These  are  usually  tender, 
and  frequently  pressure"  upon  any  part  of  the  belly  causes  pain.  In  some 
cases  free  fluctuation  can  be  detected.  If  there  be  pressure  upon  the  por- 
tal vein  by  enlarged  glands  or  caseous  masses,  the  amount  of  ascites  may 
be  large.  It  is  then  often  accomjjanied  by  oedema  of  the  lower  extremities 
and  abdominal  wall,  with  dilatation  of  the  suj)erficial  veins  of  the  belly. 
It  is  seldom,  however,  that  these  symptoms  are  noticed.  Usually  the 
amount  of  effused  fluid  is  small,  and  there  is  merely  an  imperfect  sense  of 
impiilse  conveyed  from  one  side  of  the  abdomen  to  the  other  ;  not  a  dis- 
tinct tap  of  the  wave  of  fluid,  such  as  we  feel  in  the  ascites  accompanying 
cirrhosis  of  the  liver.  If  the  amount  of  fluid  be  small,  or  its  consistence 
thick,  no  fluctuation  may  be  discovered  ;  but  in  these  cases  it  will  be 
noticed  that  on  percussing  the  belly  the  tympanitic  note  which  prevails 
over  the  greater  part  of  the  abdominal  wall  changes  in  the  flanks  to  dulness 
from  the  presence  of  fluid  ;  and  that  if  the  child  be  laid  on  one  side,  so  that 
the  fluid  may  gravitate  downwards,  the  note  on  the  flank  turned  upper- 
most becomes  clear. 

Of  these  signs  the  most  characteristic  are  :  The  enlargement  of  the 
beUy,  with  its  smooth,  shining  surface  ;  the  tenderness,  the  unequal  resist- 
ance at  different  parts  of  the  abdominal  parietes,  and  the  indistinct  fluc- 
tuation. In  some  cases,  however,  many  of  these  symptoms  may  be  absent. 
The  tenderness  may  be  insignificant  and  the  parietes  perfectly  flaccid  ; 
fluctuation  may  be  completely  absent;  and  nowhere  may  any  sense  of 
resistance  be  experienced  by  the  hand  pressing  the  abdomen.  Thus,  in  a 
little  boy  of  four  years  old,  after  three  weeks  of  illness  it  was  noted  : 
"  Abdomen  large  and  smooth,  with  loss  of  natural  markings  ;  superficial 
veins  of  chest  and  epigastrium  dilated  ;  abdominal  wall  perfectly  flaccid  ; 
no  fluctuation  to  be  detected  ;  edge  of  liver  felt  one  finger 's-breadth  below 
the  ribs  ;  edge  of  spleen  not  felt ;  several  lumps  about  the  size  of  a  walnut 
can  be  perceived  in  different  parts  of  the  abdomen,  but  not  very  deeply 
placed.  One  of  them  is  immediately  below  the  edge  of  the  liver.  They 
seem  tender  on  pressure,  but  there  is  no  general  tenderness  of  the  belly. 
Chest  healthy.  Tongue  dry  and  glazed-looking."  The  temperature  that 
evening  was  98.6°.  The  child  died  about  a  week  after  this  note,  of  second- 
ary tubercular  meningitis.  If,  in  such  a  case,  the  liver  be  much  enlarged 
from  fatty  infiltration,  a  very  incorrect  opinion  is  likely  to  be  formed  of 
the  nature  of  the  illness. 

As  the  disease  progresses,  the  skin  often  gets  very  harsh  and  rough. 
The  child  looks  haggard  and  distressed  ;  he  rapidly  wastes,  and  his  temples 
and  cheeks  grow  hollow.  He  lies  on  his  back,  or  turned  partly  on  to  his 
side,  with  his  knees  drawn  up,  and  every  movement  is  painful.      The 


696  DISEASE   IjST    CHILDREIN'". 

tongue  is  drr,  and  is  either  thickly  furred  or  is  clean  and  shining,  as  if  de- 
nuded of  epithehum.  The  appetite  is  lost ;  the  thii-st  is  great,  and  the 
bowels  are  generaU}"^  relaxed.  Often,  the  motions  consist  of  dark,  wateiy, 
offensive  matter,  with  a  flaky  deposit  containing  black  clots  of  blood.  Such 
a  stool  is  very  characteristic  of  ulceration  of  the  bowels.  Instead  of  diar- 
rhoea, there  may  be  constipation  which  may  prove  obstinate.  Fatal  ob- 
struction, even,  may  ensue.  Sometimes  at  this  period  the  distention  of 
the  abdomen  becomes  very  great,  and  the  child  is  tormented  v^ith  spasms 
of  colicky  pain.  In  other  cases,  the  size  of  the  belly  diminishes,  and  hard, 
tender  lumps  are  felt,  ajDpai-ently  in  firm  contact  with  the  under  surface  of 
the  abdominal  paiietes.  The  temperature,  which  before  was  variable  and 
often  little  raised  above  the  normal  level,  now  becomes  higher,  and  in  the 
evening  may  reach  to  between  103°  and  104°.  The  emaciation  of  the 
child  is  gTeat,  and  his  weakness  extreme. 

T\'hen  the  disease  reaches  this  stage,  improvement  rarely  takes  place  ; 
but  at  an  earlier  period  of  the  illness  it  is  not  uncommon  for  the  malady 
to  take  a  favourable  tui-n.  The  tenderness  and  tension  of  the  beU}-  then 
diminish  and  disappear  ;  the  appetite  returns  ;  the  diaiThoea  ceases ;  the 
nutrition  of  the  child  improves,  and  he  begins  to  regain  flesh.  The  fa- 
voui'able  change  may  go  on  in  fortunate  cases  to  complete  recovery,  and 
although  the  belly  for  a  long  time  remains  large,  there  is  no  return  of  the 
serious  symptoms.  Often,  however,  after  a  longer  or  shorter  interval,  the 
child  begins  to  fail  once  more  ;  inflammation  is  lighted  up  again  in  his 
peritoneum,  and  this  time  the  illness  goes  on  uninterruptedly  to  the  end. 

In  some  cases,  the  course  of  the  disease  is  very  variable,  and  is  broken 
by  occasional  periods  of  remission  in  which  hopes  of  amendment  are  raised 
only  to  be  disappointed  by  an  early  return  of  the  worst  symptoms.  Often, 
the  end  of  the  disease  is  jDreceded  by  pui-puiic  spots  on  the  body,  and 
by  oedema  of  the  legs,  with  no  albumen,  or  's\-ith  only  a  trace  of  it,  in 
the  uiine.  Death  may  be  hastened  by  tubercular  disease  of  other  organs, 
especially  of  the  lungs,  and  sometimes,  as  in  the  case  referred  to,  the  pa- 
tient dies  with  all  the  symptoms  of  tubercular  meningitis.  In  rare  cases, 
perforation  of  the  bowel  takes  place,  or  an  abscess  forms  at  the  umbilicus 
or  some  other  part  of  the  abdominal  wall. 

This  chronic  or  sub-acute  form  of  the  disease  is  always  slow  in  its 
course,  and  usually  lasts  several  months.  It  is  the  form  the  disease  as- 
sumes in  the  large  majority  of  cases.  Occasionally,  however,  the  periton- 
itis is  acute.  In  all  the  cases  of  acute  tubercular  peritonitis  which  have 
come  under  my  notice,  the  abdominal  disease  has  formed  part  of  a  general 
tuberculosis.  The  child  complains  of  jDain  in  the  belly,  but  an  exam- 
ination of  the  abdomen  gives  entkely  negative  signs.  There  is  no  ten- 
derness of  the  parietes,  or  pseudo-fluctuation  ;  no  caseous  lumps  can  be 
felt ;  and  the  belly,  although  full,  may  not  exhibit  any  remarkable  swell- 
ing. The  child  looks  ill,  and  is  languid;  his  appetite  is  poor,  and  his 
evening  temperatui-e  is  higher  than  natural.  Often,  his  bowels  are  relaxed. 
These  symptoms,  as  in  all  forms  of  acute  tuberculosis,  succeed  to  a  period 
more  or  less  prolonged,  of  general  but  indefinite  malaise.  After  an  illness 
lasting  a  few  days  or  a  week  or  two,  the  child  dies,  with  or  without  the 
symptoms  of  meningitis.  After  death,  his  bowels  are  found  matted  to- 
gether with  recent  lymph  ;  there  is,  perhaps,  a  little  thin  jDurulent  fluid  in 
the  peritoneal  cavity,  and  the  sigxis  of  general  tuberculosis  ai'e  discovered 
over  the  body.  In  most  cases,  the  existence  of  the  peritonitis  is  only  re 
vealed  by  post-mortem  examination. 

A  boy,  aged  four  years,  was  under  the  care  of  my  coUeagnie,  Dr.  Donkin, 


TUBEKCTTLAR   PEEITOITITIS — SYMPTOMS — DIAGIS^OSI?;.  G97 

in  the  East  London  Children's  Hospital.  The  child  was  said  to  have  been 
ill  for  two  weeks.  He  had  first  complained  of  j)ain  in  the  belly,  which 
was  full  and  distended,  and  his  bowels  were  relaxed.  The  pain  was  attrib- 
uted by  the  mother  to  ^ind,  for  it  was  relieved  by  hot  grog.  The  loose- 
ness of  the  bowels  ceased  after  a  day  or  two,  but  the  boy  remained  weak 
and  listless ;  his  feet  swelled  a  Httle  when  he  sat  up,  and  his  face  was 
noticed  to  be  puff)'  in  the  mornings.  For  two  or  three  days  before  admis- 
sion he  had  had  a  slight  cough. 

When  the  boy  came  into  the  hospital  his  face  was  a  little  puffy  about 
the  eyelids  and  bridge  of  the  nose.  The  heart  and  lungs  appeared  to  be 
normal.  His  belly  was  distended,  but  there  were  no  dilated  superficial 
Yeins  ;  no  dulness  was  noted  on  percussion  in  either  flank ;  no  enlarged 
glands  or  fluctuation  could  be  detected  ;  no  pain  or  tenderness  was  com- 
plained of  ;  and  the  liver  and  spleen  were  of  normal  size.  There  was  a 
little  oedema  of  the  scrotum,  but  none  of  the  lower  limbs.  His  urine  was 
scanty,  but  there  was  no  albumen.  Pulse,  88,  regular ;  temperature,  98°  ; 
respirations  normal.  After  a  few  days,  as  the  teiiperature  was  natural,  and 
the  boy  was  up  and  about  and  seemed  convalescent,  there  was  a  question 
of  sending  him  home.  Before  this  could  be  done,  however,  a  sudden 
change  took  place  in  his  condition.  He  became  very  drowsy,  and  was 
forced  to  return  to  his  bed.  He  then  began  to  vomit ;  his  j)ulse  was  80 
and  intermittent :  his  temperature  rose  again,  and  he  seemed  at  times  to 
be  only  half  conscious.  Three  days  after  his  return  to  his  bed,  the  boy 
had  an  attack  of  convulsions  ;  his  temperature  went  up  to  108°,  and  he 
died.  On  examination  of  the  body,  there  was  found  a  basic  meningitis 
with  many  gray  granulations  in  the  cranium.  Similar  granulations  were 
seen  on  the  pleurae.  The  peritoneum,  both  parietal  and  visceral,  was  pro- 
fusely studded  over  with  gray  and  yellow  granulations,  varying  in  size 
from  a  pin's  head  to  a  pea ;  and  there  was  much  recent  lymph,  which 
had  matted  together  the  coils  of  intestine,  and  fixed  them  with  the  omen- 
tum to  the  abdominal  wall.  There  was  no  excess  of  fluid  in  the  peritoneal 
cavity. 

Such  a  case  is  very  perplexing.  The  only  symptoms  pointing  to  the 
abdomen  are  the  abdominal  swelling  and  pain  ;  but  these  alone,  in  the 
absence  of  tension  and  tenderness  of  the  parietes,  or  other  equally  charac- 
teristic symptom,  are  insufficient  to  establish  the  diagnosis  of  peritonitis. 
Pain  in  the  belly  is  a  symptom  so  frequently  met  with  in  the  child  that  its 
occurrence  excites  little  remark  ;  and  a  large  belly  in  young  subjects  is 
not  sufficiently  uncommon  to  attract  sj)ecial  attention.  Still,  if  we  are 
aware  that  the  illness  may  run  this  rapid  course,  such  symptoms,  taken  in 
connection  with  the  general  weakness,  the  slight  oedema  without  albumi- 
nuria, and  the  terminal  manifestations  of  ci-anial  disease,  may  justify  us  in 
at  least  suspecting  the  existence  of  the  abdominal  complication. 

Diagnosis.  — In  ordinary  cases,  the  diagnosis  of  tubercular  j^eritonitis  is 
easy.  Inflammation  of  the  peritoneum  developing  slowly  and  insidiously, 
accompanied  by  rapid  wasting  and  a  very  variable  temperature,  and  pre- 
ceded by  general  impainnent  of  nutrition  and  abdominal  pain,  is  very 
suspicious  of  tubercle.  We  must  remember  that  tenderness  and  tension 
of  the  abdominal  waU  may  be  little  pronounced,  and  that  fluctuation  is 
often  absent,  or,  if  j)resent,  is  usually  imj^erfect  and  indistinct.  A  definite 
tap  readily  transmitted  through  the  fluid  from  one  side  of  the  abdomen  to 
the  other,  although  met  with  in  rare  cases  of  tubercular  peritonitis,  is  yet 
not  at  all  characteristic  of  this  disease.  Indeed,  if  such  free  fluctuation* be 
present  in  a  child  who  is  lively  and  fairly  active,  it  tells  rather  against  than 


698  DISEASE   IX   CHILDEEX. 

in  favour  of  the  diagnosis.  In  doubtfiil  cases,  it  is  desirable  to  test  the 
effect  of  a  sudden  jar  upon  the  child.  If  he  be  made  to  jump  down  to  the 
gi'oujid  fi'om  a  low  chair,  and  experience  no  uneasiness  fi'om  the  httle 
shock,  it  is  imjDrobable  that  the  peritoneum  is  inflamed.  A  child  with 
abdominal  tubercular  disease  is  invariably  dull  and  hstless  fi'om  the 
earliest  period  of  the  disease.  He  looks  ill  from  the  fii'st ;  and  although 
he  may  be  fairly  stout,  there  are  usually  signs  that  his  nutrition  is  ah'eady 
imj)au'ed.  These  symptoms  are  of  great  importance  when  combined  with 
abdominal  pain,  swelling,  and  tenderness.  Chi'onic  digestive  derange- 
ments are  common  in  early  life,  and  I  have  known  children  who  have  been 
habitually  overfed  with  farinaceous  food,  to  be  subject  for  months  together 
to  attacks  of  abdominal  jDam,  often  of  great  severity.  But  such  children 
are  hvely  and  active  enough  ;  although  pale  and  often  flabby,  they  do  not 
look  ill ;  they  have  not  the  careworn,  haggard  expression  which  is  almost 
inseparable  fi'om  serious  disease  at  every  period  of  life  ;  and  although  the 
abdomen  may  be  full  and  sometimes  painful,  the  fulness  is  variable,  often 
subsiding  completely ;  there  is  no  tenderness  or  involuntary  tension  of 
the  parietes,  and  the  temi^erature  is  that  of  health.  Such  cases  are  easily 
cured.  Limiting  the  consumption  of  farinaceous  matters,  a  gentle  aperient, 
and  an  alkaline  aromatic  mixture,  will  soon  put  an  end  to  the  indisposi- 
tion. 

The  acute  form  of  tubercular  peritonitis  is  often  puzzling,  especially 
if,  as  in  the  case  referred  to  above,  the  abdominal  symptoms  are  limited  to 
some  swelling  and  pain.  In  such  a  case,  typhoid  fever  is  often  suspected, 
and  the  pyrexia,  wasting,  and  increasing  weakness  may  seem  to  give 
strength  to  this  opinion.  No  evidence  is  to  be  derived  from  the  state  of 
the  bowels  ;  for  whether  confined  or  relaxed,  either  condition  is  perfectly 
compatible  with  enteric  fever.  Even  if  more  distinct  evidences  of  peri- 
tonitis occui',  these  may  be  attributed  to  perforation  and  consequent  in- 
flammation. Still,  the  absence  of  rash  and  of  splenic  enlargement,  the 
comparatively  moderate  pyrexia,  and  the  more  haggard  aspect  of  the 
patient  are  not  in  favour  of  typhoid  fever ;  and  if  fluctuation  can  be  de- 
tected in  the  abdomen,  or  slight  oedema  of  the  legs  and  face  is  noticed,  this 
disease  may  be  at  once  excluded. 

Prognosis. — Tubercular  peritonitis  is  not  invariably  fatal,  and  there- 
fore we  should  not  at  an  early  period  of  the  illness  act  as  if  the  case  were 
a  hopeless  one.  Tension  and  tenderness  are  important  symptoms,  and  if 
the  child  Ues  in  one  position,  with  his  knees  raised,  apprehensive  of  the 
least  movement,  the  sign  is  not  of  favoru-able  imiDort.  A  profuse  diaiThoea 
or  the  passage  of  stools  indicating  ulceration  of  the  bowels  must  be  viewed 
with  apprehension.  If  the  tenderness  is  extreme,  and  solid  tubercular 
masses  can  be  felt  underneath  the  abdominal  parietes,  recovery,  although 
possible  is  very  unlikely.  Also,  the  presence  of  signs  indicating  tuber- 
cular disease  of  other  organs  is  of  course  to  be  taken  as  of  serious  omen. 

On  the  other  hand,  increased  regularity  in  the  stools,  improvement  of 
appetite,  reduction  of  pyrexia,  diminution  or  subsidence  of  abdominal  ten- 
derness, and  return  of  cheerfulness  are  all  encouraging  signs.  We  must 
remember,  however,  that  alternations  of  improvement  and  relapse  are 
common  in  this  disease,  and  that  recovery,  although  not  exactly  uncommon, 
is,  at  any  rate,  an  exceptional  termination  to  the  illness. 

Treatment. — Absolute  rest,  hot  apphcations  to  the  abdomen,  and  opium 
internally,  form  the  most  useful  means  at  oui-  disposal  for  promoting  the 
subsidence  of  the  disease.  The  child  should  be  put  to  bed,  and  his  belly 
should  -  be   kept   covered  with  hot  huseed-meal  poultices,  frequently  re- 


TUBEECULAR   PERITONITIS — TREATME]S"T.  699 

newed.  If  the  weight  of  these  be  complained  of,  and  there  is  much  pain 
and  tenderness,  gTeat  rehef  is  often  derived  from  smearing  the  surface 
with  a  salve  composed  of  extract  of  belladonna  and  glycerine  in  equal  pro- 
portions, and  covering  this  with  a  thick  layer  of  cotton- wool.  The  child 
should  take  a  draught  containing  a  few  drops  of  laudanum  every  night, 
and  if  his  stomach  will  bear  it,  cod-hver  oil  may  be  administered.  Diar- 
rhoea should  be  treated  with  full  doses  of  bismuth  and  a  drop  or  two  of 
tincture  of  opium  two  or  three  times  a  day  ;  or  three  or  four  grains  of  ex- 
tract of  hsematoxylum  may  be  combined  with  three  drops  of  laudanum 
and  three  of  ipecacuanha  wine  in  a  chalk  mixture  for  a  draught  to  be 
taken  several  times  in  the  twenty-four  hours.  Purging  will  also  be  re- 
Heved  by  a  small  injection  of  starch  and  laudanum,  given  at  night.  If 
there  be  constijDation,  it  is  better  to  avoid  aperients  and  trust  to  injections 
to  reheve  the  bowels.  When  necessary,  the  accumulation  can  be  cleared 
away  by  a  good  enema  of  soap  and  warm  water. 

The  diet  of  the  child  should  be  regulated  to  suit  his  powers  of  diges- 
tion. Strong  beef-tea  and  other  broths,  milk,  yolk  of  egg,  minced  mutton 
or  chicken,  fish,  bread  and  butter,  and  light  pudding  should  be  given. 
But  great  attention  should  be  paid  that  excess  of  farinaceous  matter  is 
not  allowed,  as  acidity  and  flatulence  wiU  increase  the  discomfort  of  the 
patient  and  be  decidedly  injurious.  A  stimulant  is  required  as  the  strength 
begins  to  fail.  The  brandy-and-egg  mixture  of  the  British  Pharmacopoeia 
is  the  best  form  in  which  this  can  be  administered. 


CHAPTER  XIY. 

ASCITES.  * 

An  accumulation  of  fluid  is  sometimes  met  with  in  the  peritoneal  cavity 
in  the  child  as  a  result  of  various  causes,  and  it  is  not  always  easy  to  refer 
the  symjDtom  to  its  true  origin. 

Causation. — In  childhood,  as  in  after  life,  ascites  may  be  the  consequence 
of  j)eritoneal  inflammation  ;  of  obstruction  to  the  flow  of  blood  through  the 
portal  vein  ;  and  of  causes  which  influence  the  systemic  circulation. 

In  peritonitis  the  quantity  of  fluid  is  rarely  great,  and  sometimes  it  is 
so  smaU  that  it  is  with  difficulty  detected.  Even  in  the  subacute  perito- 
nitis which  is  the  result  of  tuberculosis  of  the  serous  Uning  of  the  abdomen, 
there  is  rarety  great  excess  of  fluid.  In  both  cases,  the  symptoms  connected 
with  the  belly  may  be  so  little  characteristic  that  the  disease  passes  com- 
j)letely  unnoticed,  and  is  only  discovered  after  death. 

The  circulation  of  blood  through  the  portal  vein  may  be  obstructed  by 
causes  which  act  within  the  liver  substance  or  aflfect  the  venous  channel  be- 
fore its  entrance  into  the  organ.  Cirrhosis  of  the  hver  may  cause  great  im- 
pediment to  the  portal  circulation  ;  and  there  is  every  reason  to  believe 
that  this  form  of  disease  is  less  uncommon  in  the  child  than  was  at  one  time 
supposed.  So,  also,  hepatic  induration  resulting  from  congestion  of  the  or- 
gan may  be  attended  by  the  same  result.  A  hydatid  of  the  hver,  if  placed 
near  to  the  concave  surface  of  the  gland,  may  cause  sufiicient  interference 
with  the  flow  of  blood  from  the  abdominal  viscera  to  lead  to  serous  effusion. 
In  the  rare  cases  in  which  the  liver  is  the  seat  of  a  mahgnant  disease,  ascites 
may  also  occur;  and  I  have  known  it  to  be  produced  by  syphilitic  gum- 
mata  of  the  hver  in  a  young  baby. 

Of  causes  Ipng  outside  the  liver,  the  most  common  is  the  presence  of  a 
mass  of  caseous  glands  in  the  hepatic  notch.  This  will  press  upon  the  por- 
tal vein  as  it  enters  the  transverse  fissure.  Pressure  may  also  be  exercised 
upon  the  vein  by  malignant  or  lymphomatous  growths  of  the  mesentery, 
but  these  are  very  rarely  met  vvdth. 

Of  the  causes  which  act  through  the  general  circulation,  heart  diseaf^e 
takes  the  first  j)lace.  It  is  common  in  cardiac  lesions  to  find  ascites  com- 
bined with  general  oedema,  and  very  often  serosity  is  poured  out,  not  only 
into  the  peritoneum  and  subcutaneous  tissue,  but  also  into  the  pleural  cavity. 
Disease  of  the  lungs  seldom  gives  rise  to  ascites  in  young  subjects  ;  and  in 
cases  of  Bright's  disease,  although  general  drojDS}'  is  common,  abdominal 
effusion  is  more  rarely  seen.  Extreme  antemia  is  sometimes  attended  by 
ascites,  but  this  is  not  a  frequent  result  of  mere  impoverishment  of  blood. 

Symptoms. — In  a  marked  case  of  ascites,  the  belly  is  distended  and 
globular.  As  the  child  lies  on  his  back  the  outline  of  the  abdomen  is  more 
rounded  than  in  the  erect  position,  for  the  fluid  gravitates  and  tends  to  col- 
lect in  the  flanks  and  swell  them  out.  The  skin  of  the  belly  is  smooth  and 
shining,  and  may  be  tense.     The  umbilicus  is  generally  prominent,  and  often 


ASCITES — SYMPTOMS.  701 

the  superficial  veins  of  the  abdominal  wall  are  unnaturally  visible.  When 
the  observer  places  his  hands  one  on  each  side  of  the  belly,  a  shght  tap 
of  the  finger  sends  a  distinct  impulse  through  the  fiuid  to  strike  against 
the  hand  in  contact  with  the  opposite  wall  of  the  abdomen.  This  sense  of 
fluctuation  is  not  stopped  by  pressure  made  in  the  middle  line  of  the  belly. 

On  percussion,  the  note  is  clear  over  the  upper  part  of  the  belly,  and 
dull  in  the  flanks.  The  dulness  varies  according  to  the  position  of  the 
child,  as  the  fiuid  always  sinks  to  the  most  depending  part  of  the  abdomi- 
nal cavity.  Consequently,  the  side  turned  uppermost  always  gives  a  reso- 
nant note.  If  the  amount  of  fiuid  be  very  large,  the  dulness  may  be  general, 
except,  perhaps,  over  the  region  of  the  stomach  and  transverse  colon.  In 
such  cases  there  is  usually  dyspnoea  from  interference  with  the  action  of 
the  diaphragm ;  and  this  is  often  so  distressing  that  the  child  cannot  lie 
down  in  his  bed.  It  may  be  accompanied  by  a  certain  amount  of  collapse 
of  the  bases  of  the  lungs.  The  pressure  of  the  accumulated  fiuid  may  also 
set  up  oedema  of  the  lower  extremities  and  genitals,  and  this  quite  irrespect- 
ive of  cardiac  disease. 

In  ascites,  although  excess  of  fiuid  wiU  excite  discomfort  and  distress, 
there  is  seldom  actual  pain  unless  the  peritoneum  be  infiamed.  Still  grip- 
ing pains  may  be  sometimes  complained  of.  These  are  due  probably  to 
the  interference  with  digestion  set  up  by  the  congested  state  of  the  gastric 
and  intestinal  mucous  membrane.  For  the  same  reason,  looseness  of  the 
bowels  is  a  not  uncommon  symptom.  The  appetite  is  often  good ;  the 
tongue  is  usually  clean  ;  and,  in  non-infiammatory  cases,  the  temperatui'e  is 
that  of  health.  Often  the  skin  is  dry  and  the  secretion  of  ui'ine  scanty,  high- 
coloured,  and  perhaps  albuminous. 

Other  symptoms  may  be  present,  according  to  the  disease  of  which  the 
peritoneal  effusion  is  the  consequence.  If  there  be  peritonitis,  the  tempera- 
ture is  generally  elevated,  and,  in  ordinary  cases,  there  is  tenderness  of  the 
belly  with  abnormal  tension  of  the  waU,  We  must  not,  however,  always 
expect  such  definite  signs.  As  described  elsewhere,  peritonitis,  hke  jDleurisy 
and  pericarditis,  may  be  completely  latent,  accompanied  by  none  of  the 
characteristic  phenomena  by  which  its  presence  is  usually  revealed.  In 
peritonitis  the  amount  of  fiuid  is  smaU,  as  a  rule  ;  and  fiuctuation  is  often 
far  from  being  distinct.  A  scanty  secretion  may  gravitate  into  the  pelvis 
and  thus  escape  detection  on  superficial  examination  ;  or  may  be  retained 
in  the  coils  of  intestine  by  adhesion  of  the  coats  of  the  bowel  to  one  an- 
other. Evidence  of  fiuid  may,  however,  be  often  obtained  by  placing  the 
patient  for  some  minutes  on  his  side,  according  to  the  plan  advocated  by 
Duparcque.  The  effusion  will  then  gravitate  into  the  undermost  fiank. 
Afterwards,  by  turning  the  child  quickly  on  to  his  back  and  examining  the 
region  lately  depending,  dulness  and  signs  of  fiuctuation  will  be  often  dis- 
covered before  the  fiuid  sinks  away  again  from  the  sui-face.  Another  plan 
is  to  place  the  child  upon  his  elbows  and  knees  ;  the  fluid  then  gravitates 
to  the  umbilical  region  and  gives  the  usual  evidence  of  its  presence. 

In  cases  of  hepatic  cirrhosis,  the  peritoneal  effusion  is  usually  copious, 
and  fiuctuation  very  distinct.  The  spleen,  in  these  cases,  is  often  en- 
larged ;  signs  of  digestive  distui'bance  are  noted  ;  the  skin,  in  advanced 
cases,  has  an  earthy  tint,  or  may  even  be  jaundiced  ;  the  veins  of  the  ab- 
dominal wall,  especially  in  the  umbilical  region,  are  unnaturally  prominent ; 
and  signs  of  dilated  hsemorrhoidal  veins,  even  in  young  subjects,  may  be 
sometimes  detected. 

When  the  ascites  is  due  to  cardiac  disease,  there  is  general  anasarca ; 
the  Ups  are  bluish  and  the  complexion  hvid ;  the  jugular  veins  are  full 


702  DISEASE   IIST   CaaiLDEEN. 

and  pulsating,  and  often  fill  from  below  ;  the  breathing  is  oppressed.  The 
urine  is  scanty  and  albuminous  ;  effusion  into  the  pleiu'al  cavities  may  be 
perhajDS  discovered,  and  an  examination  of  the  heart  at  once  reveals  the 
cause  of  the  obstructed  circulation. 

Diagnosis. — A  large  belly  is  no  sign  of  ascites.  The  abdomen  in  a 
young  child  is  always  relatively  large  as  compared  with  the  rest  of  his 
body  ;  and  if  the  child  be  the  subject  of  rickets,  or  be  injudiciously  fed, 
or  suffer  from  looseness  of  the  bowels,  the  disproportionate  size  of  his  belly 
is  still  further  exaggerated.  Flatulence  is  the  commonest  cause  of  abdom- 
inal distention  in  the  child,  and  the  increase  in  size  from  this  reason  is 
sometimes  so  great  as  to  excite  serious  alarm  in  the  minds  of  the  parents. 
It  is  very  common  in  rickety  children  who  habitually  suffer  from  derange- 
ment of  the  bowels  and  consequent  fermentation  of  food.  In  this  dis- 
tress, the  flatulent  distention  is  rendered  more  conspicuous  by  the  relaxed 
state  of  the  abdominal  muscles  and  the  shallowness  of  the  pehis.  Often, 
in  these  cases,  on  palpation  of  the  belly,  an  indistinct  sense  of  fluctuation 
may  be  felt  between  the  hands,  placed  on  either  flank.  This  is  conveyed 
through  the  distended  bowels.  It  is  distinguished  from  the  impulse  con- 
veyed by  a  wave  of  fluid  by  the  effect  upon  it  of  pressiu-e  made  in  the  mid- 
dle line  of  the  abdomen.  If  fluid  be  absent,  the  tap  of  the  finger  will  then 
at  once  cease  to  be  felt  by  the  hand  placed  on  the  opposite  side  of  the 
belly. 

Enlargement  of  the  abdominal  organs  may  also  determine  the  disten- 
tion of  the  belly.  Congestion,  amyloid  and  fatty  degenerations,  hydatid 
disease,  and  hypertropliic  cirrhosis  of  the  liver  ;  a  spleen  enlarged  from 
amyloid  disease,  rickets,  or  ague  ;  a  kidney  the  se^t  of  sarcoma  or  hydro- 
nephrosis ;  cancerous  or  lymphomatous  growths  from  the  omentum  or  ab- 
dominal glands — in  aU  these  cases  the  size  of  the  belly  may  be  increased. 

The  only  test  of  ascites  is  the  presence  of  fluctuation.  This,  if  the 
amount  of  fluid  is  small,  can  often  be  obtained  by  placing  the  patient  in 
such  a  position  that  the  fluid  may  gTavitate  to  the  surface  and  thus  be 
brought  within  reach  of  the  fingers.  It  is  not  enough,  however,  to  detect 
the  presence  of  ascites.  We  have  to  ascertain,  if  possible,  the  cause  to 
which  this  excess  of  fluid  is  owing.  If  the  symptoms  of  the  determin- 
ing disease  are  well  marked,  the  diagnosis  may  be  easy.  If,  however,  the 
symptoms  are  obscure,  the  case  may  present  great  difficulty,  and  often  it 
is  impossible  to  arrive  at  a  positive  conclusion. 

A  httle  girl,  aged  seven  years,  of  healthy  parentage,  was  a  patient  in 
the  East  London  Children's  Hospital.  The  child  had  passed  through  mea- 
sles and  whooping-cough,  and  between  two  and  three  years  previously  had 
had  an  attack  of  scarlatina  which  was  followed  by  di'opsy  ;  but  this  had 
been  completely  recovered  from.  There  was  no  rheumatic  tendency  in  the 
family,  and  the  girl  herself  had  never  suflered  fi-om  rheumatic  pains,  but 
she  was  said  to  be  subject  to  biUous  attacks. 

Six  weeks  before  her  admission  she  had  begun  to  complain  occasionally 
of  feeling  cold,  and  used  to  come  back  from  school  saying  she  had  a  head- 
ache. She  also  occasionally  complained  of  pains  in  the  right  side  of  the 
abdomen,  and  sometimes  vomited.  After  these  symptoms  had  continued 
for  a  fortnight,  the  pains  became  more  severe  and  paroxysmal,  and  the 
belly  began  to  swell.  From  that  time  she  lost  flesh.  Her  appetite  had 
been  pretty  good,  and  the  bowels  usually  regular  ;  but  she  had  had  two  or 
three  attacks  of  diarrhoea,  lasting  on  each  occasion  twenty-four  hours. 
For  two  or  three  days  before  admission  she  had  had  attacks  of  shivering. 

When  first  seen,  the  gu-l  was  in  fair  condition,  and,  although  pale,  had 


ASCITES — DIAGNOSIS — PROGNOSIS.  .  703 

BO  distressed  expression  of  face.  Her  lips  were  pink.  There  was  no  yel- 
lowness of  the  sclerotics.  The  skin  was  a  little  dry,  but  not  harsh  or 
rough.  The  beUy  was  very  full  and  tense-looking.  Its  girth  was  27^ 
inches.  It  fluctuated  freely,  and  the  veins  of  the  parietes  were  unusually 
visible.  The  lower  edge  of  the  liver  could  not  be  felt ;  its  upper  border 
was  in  the  fourth  interspace.  The  spleen  was  estimated  by  percussion 
(the  child  lying  on  her  right  side)  to  reach  from  the  seventh  to  the  ninth 
rib.  There  was  no  tenderness  of  the  belly.  The  heart's  apex  was  be- 
tween the  fifth  and  sixth  ribs,  and  the  precordial  duhiess  reached  upwards 
to  the  second  rib.  On  auscultation,  a  distinct  rub  was  heard  with  the  sys- 
tole and  between  the  two  sounds  at  the  mid-sternal  base.  The  lungs  were 
healthy,  except  for  a  little  sub-crepitant  rhonchus  at  the  bases,  which  dis- 
appeared in  a  great  measure  after  a  cough.  The  child  was  thirsty,  but 
had  Uttle  appetite  ;  her  tongue  was  clean  and  rather  red.  Pulse,  128  ; 
very  intermittent,  weak  and  soft.  Her  bowels  acted  regularly  every  day, 
and  the  motions  had  a  natural  appearance.  The  urine  was  very  clear  and 
pale.  It  was  acid  ;  had  a  density  of  1.015,  and  contained  no  albumen  or 
bile  pigment.     The  temperature  on  the  morning  after  admission  was  103°. 

During  the  next  three  weeks  the  temperature  continued  to  be  febrile  ; 
the  physical  signs  in  the  chest  became  more  developed,  and  the  child 
passed  through  a  well-marked  attack  of  pericarditis  with  effusion.  As  the 
pericardial  fluid  became  absorbed,  the  ascitic  effusion  began  also  to  dis- 
appear and  the  abdomen  to  diminish  in  size.  In  four  weeks  from  the 
time  of  admission,  the  child  was  convalescent  and  was  discharged.  About 
a  month  afterwards  she  was  readmitted  with  an  attack  of  well-marked 
enteric  fever.  It  is  curious  that  during  this  illness  the  ascites  and  peri- 
carditis both  returned ;  but  they  subsided  again,  as  before,  during  con- 
valescence from  the  fever.  Eventually,  the  girl  recovered  her  health  com- 
pletely. 

The  cause  of  the  ascites  in  this  case  is  not  very  clear  ;  but  the  absence 
of  all  symptoms  pointing  to  the  liver,  combined  with  the  natural  size  of 
the  spleen,  seemed  to  exclude  cirrhosis.  The  history  suggested  peritonitis, 
and  although  the  characteristic  features  of  this  disease  were  absent,  such 
absence  is  occasionally  observed.  Taking  into  account  the  previous 
symptoms,  the  high  temperature,  the  occurrence  of  pericarditis  as  if  from 
extension  of  the  inflammation,  and  the  completeness  of  recovery,  this  view 
would  seem  to  furnish  the  most  probable  explanation  of  the  child's  illness. 

In  some  cases,  fluid  may  be  present  in  the  abdomen  from  other  causes 
than  ascites.  Thus,  a  large  hydronephrosis  which  almost  completely  fills 
up  the  cavity  of  the  belly,  may  be  accompanied  by  free  fluctuation,  evidently 
due  to  fluid  ;  and  it  may  not  be  easy  to  distinguish  this  condition  from  a 
copious  peritoneal  efiusion.  On  careful  examination,  however,  it  will  be 
usually  found  that  in  hydronephrosis  the  swelling  of  the  abdomen  is  not 
quite  syinmetrical,  but  that  the  flank  on  one  side  shows  a  greater  promi- 
nence than  on  the  other.  The  resistance  is  also  greater  over  the  site  of  the 
greatest  bulging  ;  and  although,  as  the  child  lies  on  his  back,  the  umbilicus 
is  absolutely  dull,  a  spot  can  often  be  discovered  in  the  less  prominent 
flank  where  a  clear  percussion-note  is  obtained.  Lastly,  tapping  the 
swelling  will  withdraw  a  fluid  containing  urea. 

Prognosis. — In  cases  of  ascites,  the  child's  prospects  depend  less  upon 
the  amount  of  fluid  effused  into  the  abdominal  cavity  than  upon  the  cause 
of  the  phenomenon  and  the  general  symptoms  by  which  the  effusion  is 
accompanied.  Causes  which  affect  the  system  generally,  or  impede  the 
flow  of  blood  through  the  portal  vein  as  a  consequence  of  obstruction  to 


704  DISEASE   IlSr   CHILDEEN. 

the  general  circulation,  are  especially  to  be  feared.  Thus,  ascites  from 
tubercular  peritonitis,  or  from  heart  disease,  is  a  symptom  of  serious 
import.  In  all  cases,  the  prognosis  depends  chiefly  upon  the  pathological 
condition  which  has  occasioned  the  escape  of  serosity.  If  this  cannot  be 
discovered,  we  must  judge  of  the  prognosis  by  remarking  the  state  of  the 
child's  strength,  his  temperature,  .and  his  pulse  ;  and  by  noting  the  degree 
of  efiiciency  with  which  the  skin  and  the  other  emunctories  of  the  body 
are  performing  their  functions.  The  skin  in  particular  is  an  important 
guide.  If  the  temperature  is  not  elevated,  the  urine  non-albuminous  and 
of  normal  density,  and  the  skin  of  natural  tint,  and  neither  dry  nor  harsh, 
we  may  speak  favourably  of  the  child's  chances  of  recovery. 

Treatment. — The  treatment  of  ascites  is  dependent  upon  the  illness  in 
the  course  of  which  the  symptom  has  arisen.  If  peritonitis  (simple  or 
tuberctilar)  be  present,  the  special  measures  recommended  in  the  chapters 
relating  to  those  diseases  must  be  resorted  to.  If  the  ascites  form  a  part 
of  general  dropsy  dependent  upon  heart  disease,  it  will  be  relieved  by  the 
diuretics,  purgatives,  and  cardiac  tonics  and  stimulants  which  are  found 
ef&cacious  in  that  serious  condition. 

In  cases  of  ascites  of  obscure  origin,  or  dependent  upon  disease  of  the 
liver,  iron  and  oth^r  tonics  have  often  a  marked  influence  in  reducing  the 
amount  of  fluid  in  the  peritoneum  and  improving  the  general  condition  of 
the  patient.  The  exsiccated  sulphate  of  iron  is  well  borne  by  children, 
and  may  be  given  three  times  a  day,  in  doses  of  five  grains,  to  a  child  of 
three  or  four  years  of  age.  The  tincture  of  the  perchloride  of  iron  with 
quinine  is  also  useful ;  but  whatever  form  of  chalybeate  is  used,  the  dose 
should  be  a  large  one.  Violent  purgatives  are  to  be  avoided,  but  consti- 
jDation  must  be  treated  by  suitable  doses  of  compound  liquorice  powder, 
compound  jalap  powder,  or,  if  at  the  beginning  of  the  treatment,  by  a  grain 
of  calomel  followed  by  a  saline.  The  action  of  the  skin  must  be  main- 
tained by  a  daily  tepid  or  warm  bath  ;  and  the  child  should  be  di-essed  in 
woollen  underclothing  from  head  to  foot. 

If  the  accumulation  of  fluid  be  copious,  paracentesis  should  be  per- 
formed without  hesitation  ;  and  it  is  now  generally  held  that  promptness 
in  the  performance  of  this  ojjeration  is  to  be  preferred  to  delay.  The  diet 
of  the  child,  as  in  all  forms  of  chronic  disease,  should  be  arranged  accord- 
ing to  the  state  of  his  digestion ;  and  a  watch  should  be  kept  over  his 
capacity  for  digesting  starch,  sugar,  and  all  forms  of  fermentable  food. 
An  excess  of  such  matters  would  encourage  flatulence  and  colicky  pains, 
and  must  therefore  be  avoided. 


CHAPTER  Xy. 

INTESTINAL   WORMS. 

Of  the  many  varieties  of  parasitic  worms  whicli  infest  the  alimentary  canal 
in  childhood,  three  only  are  of  special  practical  importance  from  giving 
rise  to  disturbance  or  distress.  These  are  : — The  small  thread-worm,  the 
long  rovm.d-worm  and  the  tape-worm.  There  is  one  other,  the  large 
thread- worm  (tricocephalus  dispar),  which  is  also  occasionally  met  with ; 
but  the  creature  seems  to  give  rise  to  no  symptoms,  and  is  only  discovered 
by  its  presence  in  the  stools. 

Descrijjtion. — The  small  thread-worm  (oxyuris  vermicularis),  often  called 
seat-worm,  belongs  to  the  order  nematoda.  To  the  naked  eye,  these  worms 
have  the  appearance  of  fine  white  threads.  Both  female  and  male  speci- 
mens exist  together,  the  former  being  the  larger.  In  both  sexes  the  an- 
terior part  of  the  body  is  of  fusiform  shape.  It  is  narrowed  towards  the 
head,  which  is  abruptly  truncated  and  provided  with  three  tubercles.  The 
male  is  one-sixth  of  an  inch  in  length.  Its  intestinal  tube  extends  the 
whole  length  of  its  body,  and  terminates  in  the  anus  at  about  the  middle 
of  the  tail.  The  tail  is  arranged  in  a  spiral  form.  The  penis  is  minute 
and  hook-shaped.  The  female  measures  nearly  half  an  inch  in  length. 
Its  body  ends  ui  a  long  tapering  tail,  which  is  three-pointed  at  the  end. 
Under  the  microscope  its  uterine  ducts  can  be  seen  to  contain  a  multitude 
of  ova.  The  eggs  are  long  and  unsymmetrical.  They  may  be  readily 
hatched  by  exposing  them  to  the  sun  in  a  moistened  paper  envelope,  as  in 
the  experiments  of  Vix  and  Leuckart.  When  this  is  done,  tadpole-shaped 
embryos  escape  at  the  end  of  five  or  six  hours,  and  rapidly  develope 
into  slender  worms.  It  appears  from  the  researches  of  Leuckart  and 
Heller  that  the  embryos  can  escape  from  the  ova  in  the  human  body.  Hel- 
ler states  that  their  liberation  takes  place  in  the  stomach  under  the 
influence  of  the  gastric  juice.  From  the  stomach  the  creatures  pass  into* 
the  duodenum  and  upper  bowel,  growing  rapidly  as  they  descend  the  ali- 
mentary canal ;  and  by  the  time  they  reach  the  csecum  have  arrived  at 
sexual  maturity. 

According  to  Dr.  Cobbold,  the  csecum  is  the  customary  habitat  of  these 
parasites  ;  but  they  have  a  tendency  to  migrate,  especially  into  the  sigmoid 
flexure  and  lower  rectum,  and  can  often  be  seen  moving  about  ia  the 
folds  of  the  anus. 

The  long  roimd-worm  (ascaris  lumbricoides),  often  called  lumhricus,  is 
a  large  nematode  worm  of  a  yellowish  red  colour.  The  female  is  fifteen 
inches,  and  the  male  ten  inches  in  length.  The  body  is  cylindrical,  taper- 
ing to  either  extremity,  but  more  rapidly  towards  the  head.  The  mouth  is- 
triangular,  having  three  lips.  It  is  armed  with  numerous  (about  two  hun- 
dred) microscopic  teeth.  The  alimentar}^  canal  is  simple,  without  division 
between  stomach  and  intestine.  The  tail  is  conical  and  pointed.  In  the^ 
male  it  is  curved  like  a  hook  towards  the  ventral  aspect  of  the  body  ;  in  the 
45 


706  DISEASE   IN   CHILDEElSr. 

female  it  is  straight.  The  eggs,  which,  are  excessively  numerous  in  each 
female  specimen^  are  oval  in  shape,  and  have  a  thick,  firm,  elastic,  brownish 
shell,  which  is  usually  nodulated  on  the  surface.  In  these  ova,  the  embryos 
develope  very  slowly,  for  Davaine  kept  some  alive  for  five  years  without 
perceiving  any  attempt  of  the  immature  tenants  to  escape  from  the  shell. 
These  embryos  have  a  curious  tenacity  of  life,  for  they  cannot  be  destroyed 
by  frost  or  complete  desiccation.  It  has  been  doubted  whether  the  eggs 
can  be  hatched,  and  the  embryos  escape  and  pass  through  their  develop- 
mental stages  to  maturity,  in  the  alimentary  canal  of  the  subject  infested 
vsdth  them.  It  appears,  however,  from  the  researches  of  Heller  that  this  is 
possible. 

The  lumbricus  inhabits  the  smaller  bowel,  but  is  migratory  in  its  habits, 
and  has  a  peculiar  tendency  to  wander.  The  worms  have  been  consequently 
found  after  death  in  very  curious  places.  They  have  been  seen  in  the  nasal 
passages  ;  in  the  larynx  and  bronchi  ;  in  the  ducts  of  the  liver  and  j)ancreas  ; 
in  the  gall-bladder,  and  even  in  the  cavity  of  the  peritoneum,  and  in  the 
interior  of  abscesses  communicating  with  the  abdomen.  The  worm  has  no 
power  of  penetrating  the  living  tissues,  but  can  pass  thi'ough  an  ulcerated 
surface.  Thus,  it  has  been  known  to  pass  through  an  ulcerating  lesion  of 
the  vermiform  appendix,  and  set  up  peritonitis  by  entering  the  cavity  of 
the  abdomen. 

The  tape-worm  is  a  flat,  jointed-  worm  which  belongs  to  the  order  ces- 
toda.  Sevei'al  varieties  of  this  parasite  may  be  found  in  the  human  subject. 
The  most  common  is  the  tceyiia  medio-cannellata  (the  beef  tape-worm).  The 
tcenia  solium  (the  pork  tape-worm)  is  also  met  with.  The  bothriocephalus 
latus,  another  species,  is  not  common  in  the  British  Islands,  although  it  is 
less  rare  on  the  continent  of  Europe.  There  are  other  varieties,  but  these, 
as  they  are  very  seldom  seen,  need  not  be  here  considered. 

All  these  worms  are  flat,  segmented  creatures,  destitute  of  mouth  or  ali- 
mentary canal.  The}^  grow  from  the  head,  which  developes  a  continuous 
hnear  series  of  new  joints  by  a  budding  process.  The  joints  are  quadri- 
lateral in  shaj)e.  They  are  at  first  immature,  but  as  their  distance  from 
the  head  increases,  they  become  larger  and  more  developed.  Strictly 
speaking,  the  tape-worm  is  not  a  single  parasite,  but  a  commtmity  of  indi- 
vidually distinct  creatures,  of  which  only  the  lower  or  older  memlDers  (pro- 
glottides) are  sexually  complete.  These  contain  each  their  own  organs  of 
generation,  both  male  and  female. 

Between  the  T.  medio-cannellata  and  the  T.  sohum,  the  difference  is 
chiefly  in  the  shape  of  the  head.  In  each,  the  neck  is  tapering  and  thread- 
like, and  about  an  inch  in  length.  This  passes  gTaduall}''  into  the  anterior 
part  of  the  body,  which  is  sexually  immature,  and  is  not  distinctly  jointed. 
By  degi'ees  the  transverse  lines,  which  mark  the  imperfect  divisions  of  the 
young  segments,  become  more  defined  and  more  widely  separated,  so  that, 
while  the  more  recent  segments,  or  those  nearest  to  the  neck,  are  much 
wider  than  they  are  long,  the  older  joints,  as  they  become  more  and  more 
mature,  grow  to  be  much  longer  than  they  are  broad.  Each  mature  seg- 
ment (or  proglottis)  is  about  half  an  inch  long  by  a  quarter  of  an  inch 
broad.  It  contains  an  elongated,  tubular  uterus,  branched  on  either  side  ; 
and  the  male  and  female  organs  of  generation  open  by  a  common  perfo- 
rated papilla,  which  is  placed  at  the  border  below  the  middle  line,  on  one 
side  or  the  other,  but  not  in  regular  alternation.  In  a  worm  eight  feet  long, 
the  total  number  of  joints  has  been  reckoned  at  about  eight  hundred  ;  but 
it  is  not  until  near  the  four  hundred  and  fiftieth  segment  from  the  head 
that  the  joints  begin  to  be  sexually  mature.     The  head  is  globular,  and 


IKTESTIXAL   WOEMS— DESCEIPTION— CAUSATION^.  707 

^loout  the  size  of  the  head  of  a  small  pin.  In  the  T.  sohum,  it  forms  in 
front  a  short  cylindrical  proboscis  (rostillum)  having  foui' projecting  suckers 
decorated  by  a  crown  of  twenty-six  booklets.  Li  the  T.  medio-cannellata 
there  is  no  crown  of  booklets  or  proboscis  ;  but  the  suckers  are  large  _  a,nd 
prominent,  and  there  is  usually  a  fifth  smaller  one  in  the  ordinary  position 
of  the  rostillum. 

These  worms  often  grow  to  a  great  length  and  may  measure  many 
yards.  They  infest  the  small  intestine  and  may  number  one  or  more  in 
the  same  subject.  The  eggs,  which  are  very  numerous,  he  in  the  uterine 
ducts  of  the  mature  segments  ;  and  each  contains  an  embryo  which,  in  the 
case  of  the  tsenia  sohum,  is  furnished  with  three  pairs  of  booklets. 

The  mode  of  development  of  the  creature  is  as  follows :— The  tsenia, 
unlike  the  other  worms  which  have  been  described,  does  not  pass  through 
all  the  stages  of  its  growth  from  the  o^oim  to  matua'ity  in  the  body  of  the 
same  individual,  for  the  embryo  does  not  develope  directly  into  the  perfect 
worm.  There  is  a  transitional  stage  which  requires  to  be  completed  in  the 
body  of  an  intermediary.  This  agent  is  usually  an  animal.  Thus,  when 
a  ripe  joint  filled  with  ova  is  eaten  by  an  animal,  it  passes  into  the  stom- 
ach. There,  the  eggs  are  ruptui-ed,  and  the  embryos  (pro-scohces)  escape. 
These  embryos  have  a  tendency  to  perforate  the  tissues  of  _  the  animal  by 
whom  they  are  harboured.  They  may  thus  make  their  way  into  the  cellular 
tissue  of  a  muscle,  into  the  liver  or  the  brain.  Thus  sheltered,  they  pass 
through  a  metamorphosis,  and  become  the  cysticercus  or  bladder-worm. 
The  cysticercus  cellulosse  of  pork  consists  of  a  cyst-hke  body,  with  a  head 
and  neck  like  those  of  the  fully-developed  worm.  These  are  usually  in- 
verted mthin  the  body.  As  long  as  the  cysticercus  is  unmolested  it  under- 
goes no  further  change  ;  but  when  the  flesh  of  the  animal  is  eaten  imper- 
fectly cooked,  so  that  the  vitahty  of  the  cysticercus  is  uninjured,  the 
creature  at  once  adapts  itself  to  its  new  situation,  and  attaching  itself 
to  the  wall  of  the  small  intestine,  developes  in  the  com-se  of  a  few  months 
into  the  perfect  tape-worm. 

The  bothriocephalus  latus,  in  its  general  aj)pearance,  resembles  the  two 
varieties  of  ta?nia  just  described,  but  is  rather  larger  and  may  grow  to  a 
greater  leng-th.  The  mature  joints  are  broader  than  they  are  long,  and  the 
sexual  openings  are  placed,  not  at  the  side  of  the  segment  as  in  the  taenia, 
but  in  the  middle  of  the  joint,  where  they  appear  as  rosette-shaped  patches. 
This  tape-worm,  Hke  others,  has  an  intermediate  or  larval  stage  ;  and  it 
had  long  been  suspected  that  its  ciliated  embryo  found  shelter  in  the  body 
of  some  aquatic  animal.  Dr.  Braun,  of  Dorpat,  has  lately  found  the  early 
asexual  form  of  the  bothi'iocephalus  encapsuled  in  the  intestine  of  the  pike, 
and  also  in  some  of  the  muscles,  in  the  hver,  and  in  the  spleen  of  the  same 
fish.  Dr.  Braun  gave  these  organisms  experimentally  to  dogs  and  cats, 
who  were  put  on  a  strict  diet  and  allowed  only  distilled  water  for  diiuk. 
As  a  consequence,  segments  of  the  bothriocephalus  began  quickly  to  appear 
in  the  fteces  of  the  animals. 

Causation. — The  means  by  which  thread-worms  gain  access  to  the 
human  body,  is  by  the  direct  passage  of  the  ova  into  the  mouth.  The  eggs 
•  are  often  introduced  clinging  to  fruit,  cresses,  and  various  articles  of  food. 
But  they  may  also  be  directly  conveyed  to  the  mouth  by  the  patient  him- 
self. It  has  been  said  that  the  embryo  is  liberated  from  the  egg  in 
the  child's  stomach  by  the  action  of  the  gastric  juice  upon  the  ovum.  It 
has  been  also  stated  that  each  individual  female  worm  contains  in  itself  a 
multitude  of  eggs  which  pass  out  in  large  quantities  with  the  stools.  The 
embryos  are  probably  not  liberated  from  the  ova  in  the  bowels  ;  but  if  the 


708  DISEASE  IN   CHILDEElSr. 

ova  are  re-introduced  into  the  alimentary  canal  by  the  mouth,  they  become 
exposed  to  the  action  of  the  gastric  juice  in  the  stomach,  and  their  contents 
may  be  set  free.  According  to  Dr.  Cobbold,  children  frequently  carry  the 
ova  under  their  nails  ;  for  the  irritation  to  vyhich  the  presence  of  the  oxy- 
ures  gives  rise,  obliges  them  to  seek  relief  by  scratching.  In  this  way  the 
eggs  may  be  transferred  directly  to  the  mouth. 

The  ova  of  the  lumbricus  appear  to  be  imported  through  the  medium 
of  impure  water.  This  parasite  is  said  to  be  especially  common  in  low- 
lying,  marshy  districts. 

In  the  case  of  the  tape-worm,  it  is  through  the  eating  of  imperfectly 
cooked  flesh  infested  with  the  cysticercus  that  an  individual  becomes  the 
unwilling  harbourer  of  the  parasite.  The  taenia  sohum  is  derived  from 
measly  pork  ;  the  tsenia  medio-canellata  from  beef.  In  children  who  suf- 
fer from  a  chronic  looseness  of  the  bowels,  and  are  consequently  fed  with 
pounded  raw  meat,  tape-worm  is  occasionally  met  with. 

Symi^toms. — The  most  varied  symptoms  have  been  ascribed  to  the 
presence  of  worms  in  the  bowels.  Most  of  these  are  doubtless  due  to  the 
intestinal  derangement  from  which  the  patient  is  commonly  suffering. 
That  they  are  not  a  necessary  consequence  of  the  visits  of  these  parasites 
is  shown  by  the  fact  that  it  is  not  rare  for  the  creatures  to  be  found  in  the 
stools  of  children  who  have  not  previously  exhibited  any  sign  of  discom- 
fort or  distress.  In  these  cases,  the  worms  are  usually  few  in  number,  and 
can  be  readily  got  rid  of  by  the  administration  of  an  ordinary  aperient. 
It  seems  necessary  for  the  extensive  propagation  of  the  entozoa  that  a  ca- 
tarrhal condition  of  the  bowel  should  be  present.  In  the  secreted  mucus 
the  embryos  find  a  favourable  medium  for  development,  and  if,  as  often 
happens,  the  flux  be  profuse,  great  difiiculty  may  be  experienced  in  free- 
ing the  patient  from  these  irritating  pests.  It  is  in  such  cases  only  that 
severe  general  symptoms  are  found  ;  but  these,  as  has  been  said,  are  to  be 
rightly  attributed,  not  to  the  parasites,  which  may  be  looked  upon  as  acci- 
dental complications,  but  to  the  imhealthy  state  of  the  alimentary  mucous 
membrane,  which  hinders  digestion  and  impairs  the  nutrition  of  the  body. 
These  symptoms  are  described  elsewhere  (see  page  121),  and  need  not  be 
here  repeated.  There  are,  however,  many  special  symptoms  which  are  at- 
tributed directly  to  the  presence  of  worms  ;  and  as  they  are  not  necessarily 
the  consequence  of  the  intestinal  derangement  referred  to,  and  often  cease 
when  a  number  of  worms  have  been  expelled,  it  is  possible  that  they  are 
really  due  to  the  irritation  set  up  by  the  creatures  in  the  bowels. 

Most  of  these  special  symptoms  will  be  referred  to  in  describing  the 
particular  symptoms  produced  by  the  several  sj)ecies  of  worm.  It  may, 
however,  be"^ stated  in  this  place,  that  every  variety  of  neiwous  symptom, 
from  headache,  and  other  disorders  of  sensation,  to  spasm,  paralysis,  and 
convulsions,  has  been  found  associated  with  the  presence  of  worms  in  the 
ahmentary  canal.  Some  of  these  have  been  looked  upon  as  pathogno- 
monic. Thus,  Dr.  Underwood  held  that  an  attack  of  convulsions,  accom- 
panied by  small  pulse  and  hiccough,  was  an  ahnost  certain  sigTi  of  worms. 
Monro  was  of  opinion  that  unequal  dilatation  of  the  pupils  jDointed  posi- 
tively to  the  same  conclusion.  Others  have  relied  upon  the  rapidity  and 
irregularity  of  the  pulse  as  furnishing  sufficient  grounds  for  the  diagnosis. 
It  cannot  be  denied  that  these  symptoms  may  be  noticed  in  children  suf- 
fering from  intestinal  worms,  and  may  possibly  be  produced  by  them  ;  but 
similar  symptoms  are  found  in  cases  where  careful  observation  fails  to  dis- 
cover any  sign  of  the  creatui-es  or  their  ova  in  the  stools. 

There  is  one  symptom  which,  although  not  positivelj^  distinctive  of  the 


INTESTINAL   WORMS — SYMPTOMS.  709 

irritation  of  worms  in  the  bowel,  renders  the  presence  of  the  parasites 
highly  probable.  This  symptom  is  a  pecuhar  appearance  of  the  tongue. 
In  all  cases  where  the  bowels  are  the  seat  of  a  mucous  flux,  the  tongue  gives 
evidence  of  this  condition.  It  is  flabby,  and  indented  at  the  edges  by  the 
teeth.  The  increased  secretion  of  mucus  in  the  mouth  gives  to  the  tongue 
a  shmy,  g-ummy  appearance.  The  lingual  surface  is  covered  with  a  thin 
coating  of  gray  fur,  and  the  fungiform  papillse  at  the  sides  of  the  dorsum 
peer  through  the  fur  as  round  or  oval  spots,  which  are  more  or  less  red, 
according  to  the  degree  of  irritability  of  the  stomach.  In  cases  where 
worms  are  present,  I  have  often  remarked  a  pecuhar  fawn  colour  of  the 
fur  covering  the  dorsum,  and  the  shmy  appearance  of  the  organ  has  been 
especially  noticeable. 

A  child  may  be  infested  by  more  than  one  variety  of  worm  at  the  same 
time.  It  is  not  uncommon  to  find  round-worms  together  with  thread- 
worms ;  and  sometimes  round-worms  and  tape-worms  are  present  at  the 
same  time  in  the  same  subject.  Thus,  a  little  boy,  aged  one  year  and  eight 
months,  was  under  my  care  for  tape-worm,  from  which  he  had  been  suffer- 
ing for  three  months.  This  child,  on  one  occasion,  passed  a  large  round- 
worm and  many  joints  of  the  taenia  in  the  same  stool. 

In  the  case  of  thread-ivorms,  the  patient  seldom  complains  of  abdominal 
pain,  but  the  irritation  set  up  in  the  rectum  by  the  presence  of  the  eutozoa 
gives  rise  to  a  troublesome  itching  of  the  fundament,  which  in  sensitive 
children  may  cause  an  extreme  degree  of  suffering.  This  irritation  comes 
on  towards  the  evening,  and  at  night  may  be  so  distressing  that  sleep  is 
greatly  interfered  with.  In  some  cases,  in  addition  to  the  itching,  shoot- 
ing pains  may  be  complained  of  in  the  same  part.  Catari-h  of  the  rectum 
is  not  uncommon  in  such  subjects.  There  may  be  looseness  of  the  bowels, 
and  the  evacuations  are  often  discharged  with  straining  efforts.  They  may 
be  followed  by  prolapse  of  the  rectum.  The  stools  often  contain  glairy 
mucus,  and  sometimes  blood  in  streaks,  or  even  clots  of  considerable  size. 
Difficulty  in  emptying  the  bladder  may  be  a  consequence  of  the  irritation, 
and  the  child  sometimes  holds  his  water  for  many  hours  together.  Itch- 
ing of  the  nose,  a  leaden  tint  of  the  lower  eyelid,  and  swelling  of  the  upper 
lip,  are  also  very  common  symptoms  when  thread-worms  are  present. 

The  worms  are  readily  detected  as  white  moving  threads  in  the  stools, 
and  may  be  seen  in  the  folds  of  mucous  membrane  about  the  anus.  They 
may  pass  or  be  conveyed  into  the  vagina  in  little  girls ;  and  can  often  be 
discovered  in  the  bed-clothes.  A  microscopic  examination  of  the  stools 
usually  discovers  a  multitude  of  ova. 

The  lumhricus,  on  account  of  its  large  size  and  its  habits  of  nocturnal 
activity,  is  a  cause  of  considerable  irritation.  This  worm  is  said  frequently 
to  give  rise  to  nervous  disorders  in  the  child  ;  and  cases  have  been  recorded 
in  which  severe  headache,  photophobia,  choreic  movements,  convulsions, 
and  even  profound  coma  have  ceased  on  the  expulsion  of  a  number  of  these 
creatures.  It  is  difficult  to  say  what  share  the  worms  take  in  the  produc- 
tion of  such  symptoms.  Probably  some  additional  cause  is  in  operation, 
for  in  rickety  children,  whose  tendency  to  convulsions  and  other  forms  of 
nervous  disturbance  is  one  of  the  most  characteristic  consequences  of  that 
phase  of  general  malnutrition,  I  have  not  noticed  that  the  presence  of  the 
long  round-worm  is  especially  liable  to  be  accompanied  by  eclamptic  seiz- 
ures. Probably,  in  most  cases  where  nervous  symptoms  are  associated  with 
intestinal  worms,  the  nervous  disturbance  is  quite  independent  of  any  irri- 
tation produced  by  the  worms  in  the  bowels.  It  is  common  enough  for 
children  who  are  suffering  from  undoubted  disease  of  the  nervous  centres 


710  DISEASE  IN   CHILDEEISr. 

to  be  infested  with  lumbrici.  Thus,  in  cases  of  tubercular  meningitis,  one 
or  more  long  worms  are  often  expelled  by  the  action  of  aperients ;  but  it 
is  needless  to  say  that  in  such  a  case  no  amelioration  in  the  symptoms  fol- 
lows the  expulsion  of  the  parasites.  So,  also,  children  under  my  care  suf- 
fering from  chorea  have  passed  lumbrici,  but  I  cannot  call  to  mind  a  single 
case  where  any  improvement  in  the  disease  has  directly  followed  the  ap- 
pearance of  the  worm  in  the  stools. 

If,  however,  the  nervous  symptoms  supposed  to  be  produced  by  lumbrici 
must  be  looked  upon  as  somewhat  problematical,  there  are  other  phenom- 
ena which  can  be  referred  with  much  greater  certainty  to  the  irritation  set 
up  by  the  entozoa.  Severe  abdominal  pains  of  a  colicky  character  are  not 
uncommon  in  children  who  suffer  from  these  creatures ;  and  looseness 
of  the  bowels,  occurring  chiefly  at  night,  is  occasionally  produced  by  this, 
agency.  I  have  seen  several  cases  of  this  kind  where  a  diarrhoea,  after  per- 
sisting for  months,  ceased  immediately  that  the  worm  was  got  rid  of. 

A  little  boy,  aged  four  years  and  a  half,  was  said  to  have  been  troubled 
for  three  months  with  persistent  looseness  of  the  bowels.  The  purging- 
was  never  very  severe,  but  was  always  worse  at  night.  The  motions  were 
said  to  be  very  slimy,  and  after  a  dose  of  oil,  usually  contained  thread- 
worms. The  child  often  complained  of  colicky  pain  and  tenesmus.  He  had 
been  slowly  wasting  from  the  time  the  purging  first  began.  The  occurrence 
of  nocturnal  looseness  of  the  bowels,  combined  with  the  appearance  of  the 
tongue,  which  was  very  flabby,  slimy,  and  drab-coloured,  with  large  fungi- 
form papillae  at  the  sides  of  the  dorsum,  made  me  suspect  the  presence  of  a 
long-worm.  I  ordered  a  powder  containing  one  grain  and  a  half  of  san- 
tonine  and  half  a  grain  of  calomel  to  be  given  every  night  for  three  nights, 
and  to  be  followed  each  morning  by  a  dose  of  castor-oil.  After  the  first 
powder  the  child  passed  a  long-worm,  and  the  diarrhoea  ceased  from  that, 
time.     He  then  rapidly  regained  flesh. 

As  a  rule,  lumbrici  become  active  at  night,  and  may  pass  upwards  intO' 
the  stomach,  or  downwards  into  the  colon  and  rectum.  They  have  been 
known  to  issue  spontaneously  from  the  mouth  of  a  child  during  sleep,  or  ta 
appear  from  the  bowel  without  being  discharged  in  a  stool.  Their  pres- 
ence in  the  stomach  may  give  rise  to  nausea  and  retching.  Sometimes  they 
pass  into  the  common  bile-duct  and  cause  jaundice,  by  obstructing  its  chan- 
nel. If  jaundice  rapidly  developes  in  a  child  who  is  known  to  be  troubled 
with  this  parasite,  we  should  think  of  the  possibility  of  this  rare  accident 
having  happened.  Sudden  dyspnoea  has  been  known  to  arise.  In  some 
instances,  at  least,  this  has  been  discovered  to  be  due  to  the  actual  penetra- 
tion of  the  worm  into  the  air-passages.  Thus,  Andral  has  known  death  to 
occur  from  this  cause  ;  and  Arronsshon  has  reported  the  case  of  a  Httle 
girl,  aged  eight  years,  who,  after  suffering  for  two  hours  from  distressing- 
dyspnoea  and  cough,  suddenly,  after  a  violent  paroxysm  of  cough,  ejected  a 
long-worm  and  was  immediately  relieved.  In  other  cases,  the  difficulty  of 
breathing  has  been  attributed  to  direct  pressure  upon  the  larynx  and  trachea, 
by  a  number  of  worms  in  the  gullet,  or  to  reflex  action,  propagated  from  the 
intestine  ;  but  these  explanations  are  neither  of  them  very  satisfactory.  It 
has  been  so  much  the  tendency  to  attribute  every  kind  of  discomfort  arising 
in  cases  where  worms  are  present  to  the  irritation  of  the  parasitic  creatures 
in  the  bowels,  that  probably  sufficient  care  has  not  been  always  taken  to  ex- 
clude other  and  less  obvious  causes  of  the  symptoms. 

Lumbrici  are  sometimes  present  in  very  great  quantities.  The  largest 
number  I  have  known  to  occur  together  in  one  child  has  been  twelve  ;  but 
they  are  sometimes  much  more  numerous,  and  may  even  amount  to  several 


IlSTTESTIlSrAL   WORMS — DIAGNOSIS — TEEATMEISTT.  711 

Imiidreds.  When  thus  multipHed,  the  worms  may  form  bundles,  which 
impede  the  passage  of  the  contents  of  the  bowel,  and  are  said  in  some  cases 
to  give  rise  to  the  symptoms  of  obstruction. 

The  tape-worm  is  often  found  in  children  and  sometimes  in  infants. 
One  child  who  came  under  my  own  observation  began  to  pass  the  joints 
at  the  age  of  fifteen  months.  Other  observers  have  met  vs^ith  the  worm  in 
still  younger  subjects.  •  These,  however,  are  exceptional  cases,  but  in 
older  children,  of  five  or  six  years  and  upwards,  the  affection  is  as  common 
as  it  is  in  the  adult.  In  these  patients,  little  disturbance  appears  to  be 
excited  by  the  parasites.  Pallor  and  loss  of  flesh  are  often  complained 
of  ;  but  these  symptoms,  as  in  the  case  of  the  other  species  of  parasite,  ap- 
pear to  be  due  less  to  the  worm  than  to  the  mucous  derangement  of  the 
bowel  with  which  its  presence  is  usually  associated.  Headache  and  dis- 
colouration of  the  lower  eyelid  also  often  occur,  and  may  be  attributed  to 
the  same  catarrhal  condition.  Often,  however,  the  digestion  remains 
good,  and  the  child,  except  for  occasionally  passing  segments  with  the 
stools,  is  to  all  appearance  well. 

Diagnosis. — No  symptoms  are  to  be  relied  upon  in  the  diagnosis  of 
intestinal  worms.  The  only  sign  from  which  we  can  draw  any  positive  in- 
ference, is  the  appearance  of  the  creatures  or  their  eggs  in  the  stools. 
Therefore,  if  from  any  cause  we  suspect  their  presence  in  the  bowels,  we 
should  at  once  adopt  appropriate  treatment,  and  order  the  evacuations  to 
be  carefully  searched  for  signs  of  the  parasites.  A  microscopic  examina- 
tion of  the  matters  discharged  from  the  bowels  will  often  discover  the 
presence  of  the  ova. 

Treatment. — With  the  exception  of  the  taenia,  worms  are  usually  ex- 
pelled readily  in  young  subjects  ;  but  it  is  less  easy  to  prevent  their 
frequent  reproduction.  In  all  cases  where  children  continue  to  be  in- 
fested for  long  periods  with  the  oxyures  or  lumbrici,  the  bowels  will  be 
found  to  be  the  seat  of  a  chronic  mucous  flux.  There  can  be  little  doubt 
that  in  such  cases  the  ova  lodge  in  the  abundant  secretion  and  find  in  it  a 
congenial  medium  for  develojDment.  Therefore,  in  all  such  cases,  the 
special  means  adopted  for  relieving  the  bowels  of  their  unwelcome  tenants 
must  be  conjoined  with  other  measures  for  arresting  the  chronic  derange- 
ment of  the  mucous  membrane  and  restoring  the  intestinal  canal  to  a 
healthy  state.  These  measures  consist  in  the  adoption  of  a  careful  diet, 
from  which  sweets  and  farinaceous  matters  are  in  great  part  excluded ; 
in  the  frequent  use  of  mild  aperients  to  clear  away  mucus  accumulated  in 
the  alimentary  canal ;  and  in  the  administration  of  alkaline  and  other  reme- 
dies to  check  hyper-secretion  from  the  mucous  membrane.  This  subject  is 
referred  to  elsewhei^e  (see  page  127). 

Thread-xvorms  are  most  effectually  and  easily  removed  by  the  use  of 
enemata.  For  this  purpose,  lime-water,  or  an  infusion  of  quassia,  or  a 
solution  of  common  salt  (a  teaspoonful  to  four  ounces  of  water),  may  be 
employed.  In  using  these  agents,  the  bowel  should  first  be  cleared  out 
by  a  copious  injection  of  warm  water.  Afterwards,  five  or  six  ounces  of 
the  special  enema  should  be  administered,  and  be  retained  for  a  few  min- 
utes by  pressing  the  anus  before  it  is  allowed  to  escape.  In  obstinate 
cases,  santonin  (one  grain  to  a  child  of  four  years  old)  should  be  added 
nightly  to  a  dose  of  the  compound  liquorice  powder  or  other  mild  ape- 
rient ;  and  five  grains  of  tartarate  of  iron,  with  one  or  two  drachms  of  the 
compound  decoction  of  aloes,  diluted  with  water  and  sweetened  by  a  few 
drops  of  spirits  of  chloroform,  may  be  given  two  or  three  times  a  day. 

Looseness  of  the  bowels  in  these  cases  is  readily  arrested  by  a  dose  of 


712  DISEASE  IN   CHILDEElSr. 

castor-oil.  The  nocturnal  itcliing  may  be  greatly  relieved  by  the  appli- 
cation to  the  fundament  of  an  ointment  composed  of  equal  parts  of  un- 
guentum  hydrarg-jori  and  lard,  as  recommended  by  Dr.  K.  Liveing  ;  or 
by  the  use  of  a  salve  made  by  rubbing  \\p  one  di-achm  of  finely  powdered 
camphor  with  an  oimce  of  lard.  In  all  these  cases,  the  gTeatest  cleanliness 
must  be  obsei-ved,  and  after  each  action  of  the  bowels  the  parts  should  be 
well  washed  with  soap  and  warm  water. 

In  the  case  of  lumhrici,  santonin  is  especially  indicated.  The  remedy  is 
best  combined  with  a  dose  of  calomel.  Thus,  for  a  child  of  five  or  sis  years 
old,  two  grains  of  the  former  may  be  given  wdth  half  a  grain  of  the  sub- 
chloride  of  mercury  every  night  for  two  or  three  nights,  and  be  followed 
each  morning  by  a  purgative  dose  of  castor-oU.  Employed  in  this  manner, 
the  drug  rarely  fails  to  bring  away  the  round-worm,  if  one  of  these  crea- 
tm-es  is  hidden  in  the  bowels.  Santonin  is  a  remedy  which  should  not  be 
given  in  too  large  doses.  In  some  children  it  causes  vomiting  ;  in  others 
it  produces  giddiness,  with  impau-ment  of  vision,  so  that  all  objects 
seem  tinted  with  a  green  or  j^ellow  colour.  Usually,  it  increases  the  amount 
of  urine  and  gives  a  yellow  tinge  to  the  secretion. 

For  children  who,  on  account  of  vomiting  or  other  toxic  effect  of  the 
medicine,  cannot  take  santonin  without  discomfort,  some  alterative  remedy 
must  be  used.  Cowhage  (the  hairs  of  the  mucvma  pruriens)  may  be  pre- 
scribed in  doses  of  thirty  to  sixty  gTains,  given  twice  a  day  in  treacle  or 
glycerine.  Dr.  W.  Eoe  speaks  highly  of  the  sulphites,  especially  the  bi- 
sulphite of  soda,  and  recommends  ten  or  fifteen  grains  to  be  given  three 
times  a  day  in  water  sweetened  with  spiiits  of  chloroform  and  flavoured 
with  tincture  of  orange-xaeel.  Neither  of  these  remedies  has  any  laxative 
action.  Each  should,  therefore,  be  always  followed  by  a  purgative  dose 
of  aloes,  senna,  castor-oil,  or  other  mild  aperient.  Oil  of  turpentine  is  an- 
other useful  vermifuge.  It  can  be  given  in  a  morning  dose  of  two  drachms 
(for  a  child  of  six)  combined  with  an  equal  quantity  of  castor-oil. 

It  is  not  advisable,  in  ordinary  cases,  to  continue  the  use  of  anthelmin- 
tics if  the  first  doses  have  been  given  without  effect.  It  must  not  be  for- 
gotten that  all  the  symptoms  of  worms  {i.e.,  of  irritation  of  the  bowel)  may 
be  present  although  sj)ecial  remedies  fail  to  produce  any  sign  of  the 
creatiu-es  in  the  stools.  If,  therefore,  after  a  few  trials,  no  lumbricus  is 
discovered,  we  should  attribute  the  sj-mptoms  to  the  general  intestinal 
derangement,  and  take  the  necessaiy  stejDS  to  biing  the  disorder  to  an 
end. 

The  successful  treatment  of  tape-ioorm  in  the  child  is  often  a  matter  of 
no  Uttle  difficulty.  Probably  the  softer  mucous  membrane  in  the  young 
subject  adapts  itself  more  readily  to  the  action  of  the  suckers  than  is  the 
case  in  the  adult,  for  in  my  experience  it  is  comparative^  rare  for  the 
head  to  be  discovered  in  the  evacuations.  The  joints  can  be  readily  ex- 
pelled, but  the  head  too  often  remains  behind.  In  all  these  cases,  gTcat 
care  should  be  taken  in  the  examination  of  the  stools.  All  the  visible 
joints  should  be  first  removed.  The  fsecal  matter  should  then  be  diluted 
with  water  and  emptied  slowly  from  one  vessel  into  another,  with  every 
precaution  that  the  liquid  excreta  is  thoroughly  searched  by  the  eye  as  it 
passes  over  the  side  of  the  utensil.  The  sediment  remaining  should  be 
then  again  diluted  and  strained  through  a  fine  sieve.  By  this  means,  the 
head,  if  it  have  passed  from  the  bowel,  can  scarcely  escape  notice. 

Various  kinds  of  vermifuge  are  rehed  upon  in  the  treatment  of  these 
parasites.  Kousso,  kamala,  filix  mas,  turpentine,  and  a  decoction  of  the 
fresh  bark  of  the  pomegranate  root  have  all  theii*  advocates.     Eihx  mas, 


INTESTINAL   WORMS — TEEATMENT.  713 

"which,  is  the  favoTU'ite  remedy  for  the  adult,  is  uncertain  in  the  case  of 
children.  For  young  subjects,  it  is  best  combined  with  kamala.  A  drachm 
of  powdered  kamala  is  made  into  an  emulsion  with  mucilage,  and  then 
triturated  in  a  mortar  with  a  drachm  of  fem-oil,  adding  water  slowly  to 
make  a  three-ounce  mixture.  It  is  important  that  the  remedy  be  given 
fasting.  The  child  should  be  allowed  to  take  nothing  but  a  Httle  water 
after  his  mid-day  dinner.  The  draught  should  be  given  on  the  following 
morning,  divided  into  two  portions,  of  which  the  second  half  must  be  taken 
at  an  interval  of  three  hours  after  the  first.  Kamala  has  an  aperient  action 
of  its  own.  This  method  of  treatment,  therefore,  seldom  requires  the 
assistance  of  a  purgative,  as  is  necessary  in  the  case  of  male  fern-oil  given 
alone.  After  the  two  draughts  have  been  swallowed,  the  patient  should 
still  continue  his  fast  until  the  worm  comes  away  in  the  stool.  I  have 
found  children  bear  this  method  of  treatment  well,  and  it  is  often  effectual. 
If  the  draught  excite  vomiting,  it  should  be  repeated,  preceded  by  a  small 
dose  (tT],  ij.-iij.)  of  laudanum  to  quiet  the  irritability  of  the  stomach. 

Kousso  is  preferred  by  some.  The  remedy  is  given  in  doses  of  two  or 
three  drachms  divided  into  two  portions,  and  given  at  an  interval  of  half 
an  hour  in  milk.  The  draught  should  be  taken  in  the  early  morning,  and 
should  be  followed  in  an  hour  after  the  second  dose  by  a  spoonful  of  castor- 
oil.  The  principal  objection  to  this  method  of  treatment  is  the  large 
quantity  of  the  drug  which  it  is  necessary  to  swallow  in  order  to  produce 
any  satisfactory  effect.  The  same  objection  applies  to  the  decoction  of  pome- 
granate bark.  If  these  remedies  fail,  turpentine  should  always  be  tried. 
This  on  may  be  given  in  one  large  dose,  or  in  smaller  quantities  frequently 
repeated.  In  the  large  dose  it  may  be  administered  as  recommended  for 
the  lumbricus.  In  smaller  quantities.  Dr.  H.  Davies  recommends  half  a 
di'achm  to  be  mixed  with  honey  and  given  in  a  draught  with  mucilage  and 
water  every  six  hours.  Every  second  morning  he  orders  a  powder  of 
calomel  and  the  compound  scammony  powder. 

In  all  cases  where  there  is  much  derangement  of  the  bowels,  and  large 
quantities  of  mucus  are  passed  in  the  stools,  a  rigid  diet,  from  which  starchy 
matters  and  sweets  are  carefully  excluded,  should  be  enforced  for  at  least 
a  week  before  the  special  treatment  is  undertaken.  This  precaution  greatly 
increases  our  chances  of  success. 


art  10; 
DISEASES  OF  THE  LIVER. 


CHAPTER  I. 

JAUNDICE. 


Jathstdice  is  common  in  early  life.  This  symptom  may  be  found,  in  cliildren 
as  a  consequence  of  the  same  causes  which  produce  it  in  the  adult.  There 
is  in  addition  a  special  foim  of  jaundice  seen  in  new-born  babies  which  is 
called  icterus  neonatorum.  It  will  be  therefore  convenient  first  to  describe 
javmdice  as  it  occui's  in  the  new-born  baby,  and  afterwards  the  symptom 
as  it  is  met  with  in  older  children. 

Icterus  neonatorum,  or  infantile  jaundice,  must  be  distinguished  from 
the  yellowish  discolouration  of  the  skin  which  succeeds  in  many  cases  to 
the  intense  cutaneous  congestion  of  the  first  few  houi's  or  days  of  life. 
This  staining  is  not  dependent  upon  the  secretion  of  bile,  and  is  not  a 
jaundice  at  all.  It  does  not  colour-  the  conjunctivae  or  the  ui-ine,  but  re- 
sembles the  staining  of  the  skin  which  foHows  a  cutaneous  bmise.  The 
face  of  the  child  who  is  born  after  a  difficult  or  tedious  laboiir,  is  often  at 
first  deep  red,  with  a  tinge  of  violet ;  and  the  skin  over  the  bod}^  is  coloured 
with  an  erythematous  redness.  At  the  same  time,  or  soon  after,  j)i'essui'e 
upon  the  surface  sufficiently  fii'm  to  empty  the  blood-vessels  shows  a  yellow 
tint  of  the  skin.  As  the  redness  fades,  the  yellowness  appears  to  increase, 
and  soon  remains  the  sole  discolouration.  Beginning,  as  a  rule,  on  the 
second  day,  it  usually  persists  for  about  a  week,  and  is  commonly  over  by 
about  the  tenth  day,  or  a  httle  earher,  although  in  exceptional  cases  it  may 
last  longer.  By  some  writers,  the  term  icterus  neonatorum  is  confined  to 
this  false  jaundice,  and.  the  same  authors  apply  the  name  icterus  infantum 
to  the  true  disease.  This  practice  is  calculated  to  give  rise  to  unnecessaiy 
confusion.  In  the  follo^^ing  pages  the  terms  icterus  neonatorum  and 
icterus  infantum  will  be  applied  indifferently  to  indicate  a  staining  of  the 
skin  by  the  pigments  of  the  bile. 

Real  icterus  manifests  itself  in  the  child  as  it  does  in  the  adult,  by  a 
yellow  tint  of  the  skin  and  conjunctivae,  light-coloured  stools,  and  often  by 
discolouration  of  the  mine.  It  may  be  the  result  of  some  comparatively 
trifling  derangement,  and  is  then  readily  recovered  from  ;  or  may  be  the 
consequence  of  a  serious  malformation  or  grave  organic  lesion,  and  is  then 
almost -invariably  fatal. 


JAUISrDICE — ICTERUS   ISTEOIS^ATOEUM.  715 

The  milder  form  of  jaundice — whicli  may  be  called  the  benign  variety 
— appears  to  be  predisj)osed  to  by  difficulty  and  delay  in  the  process 
of  parturition.  A  first-born  child,  exj)osed  to  serious  and  prolonged 
pressure  before  birth,  and  who,  in  consequence,  is  born  in  a  state  of  semi- 
asphyxia,  is  often  found  to  become  jaundiced.  Again,  according  to  Kehrer, 
premature  birth,  or  other  cause  of  weakness  in  the  infant,  is  apt  to  be  fol- 
lowed by  the  same  result.  Exposure  to  cold  and  damp,  and,  according  to 
some  writers,  a  "vitiated  atmosphere,  can  also  produce  it. 

Many  theories  have  been  advanced  to  account  for  the  frequency  of  this 
symptom  in  the  newly  born.  Virchow  attributed  it  to  a  duodenal  catarrh, 
and  plugging  of  the  common  duct  with  mucus  ;  and  in  children  who  have 
been  exposed  to  cold  this  is  no  doubt  a  common  cause  of  the  derange- 
ment. Frank  thought  it  was  the  consequence  of  an  accumulation  of  me- 
conium. Cohnheim  believed  it  to  be  due  to  a  sudden  increase  in  the  bile 
secretion  after  birth — an  increase  too  great  for  the  bile-ducts  to  carry 
away  ;  but  he  has  advanced  no  evidence  ill  support  of  his  theory.  Many 
writers  have  referred  the  symptom  to  the  disturbance  in  the  hepatic  circu- 
lation consequent  upon  the  change  in  the  conditions  of  life  incident  to 
birth.  The  circulation  is  too  full,  according  to  Hewitt  and  Weber,  so  that 
the  distended  vessels  compress  the  bile-ducts  ;  it  is  too  empty,  according 
to  Frerichs,  the  circulation  through  the  umbilical  vein  being  suddenly  cut 
off,  and  the  tension  of  the  hepatic  capillaries  diminished,  so  that  the  se- 
creted bile  makes  its  way  into  the  blood-vessels. 

There  can  be  no  doubt  that  the  sudden  transference  of  the  chief  sup- 
ply of  blood  from  the  umbihcal  to  the  portal  vein  must  at  first  produce 
considerable  distiu-bance  in  the  hepatic  circulation.  Weber  has  pointed 
out  that  if  the  functions  of  the  umbilical  vein  are  arrested  before  the  es- 
tabhshment  of  respiration,  as  when  a  child  is  born  partially  asphyxiated, 
great  congestion  and  oedema  of  the  hver  are  the  consequence.  Birch- 
Hirschfeld  has  shown  that  the  vessels  in  the  notch  of  the  liver  are  sur- 
rounded by  a  dense  layer  of  connective  tissue,  and  that  this  areolar  sheath 
is  continued  into  the  organ  along  the  branches  of  the  portal  vein.  He 
has  noted  that  in  cases  of  difficult  partiirition,  where  the  liver  is  the  seat 
of  great  venous  obstruction,  this  areolar  sheath  is  oedematous.  It  becomes 
pulpy  and  gray  in  colour  from  infiltration  of  fluid,  and  a  gTeat  accumula- 
tion of  round  cells  takes  place  into  its  meshes.  This  pulpy  condition  of 
the  cellular  layer  is  seen  also  around  the  umbihcal  vein,  and  may  even 
extend  into  the  gall-bladder.  It  is  evident  that  the  swollen  tissue  must 
compress  the  bile-ducts,  and  Birch-Hirschfeld  has  shown  that  this  is 
actuaUy  the  case.  The  bile-ducts  are  distended,  and  it  is  difficult  to  force 
bile  out  of  the  gall-bladder  into  the  duodenum.  In  these  cases  he  has  de- 
tected earlv  signs  of  jaundice  where  death  has  occurred  during  the  first 
day,  and  reports  cases  in  which  hfe  had  been  further  prolonged  with  a 
gradual  increase  in  the  icteric  symptoms.  In  these  mild  eases,  the  jDres- 
ence  of  the  bile-pigment  cannot  be  always  demonstrated  in  the  urine  ; 
but,  according  to  this  authority,  the  bile  acids  can  be  detected  in  fatal 
cases  in  the  pericardial  fluid. 

"V\Tien  the  icterus  is  a  consequence  of  the  condition  above  described,  it 
is  seldom  very  severe.  In  the  mildest  cases  the  conjunctivae  are  only 
faintly  tinted  with  yellow  ;  the  appearance  of  the  urine  and  the  motions  is 
normal ;  and  the  staining  of  the  skin  is  only  noticed  on  the  face,  the  front 
of  the  chest,  and  the  back.  The  derangement  is  then  only  a  passing  one, 
and  the  skin  resumes  its  natural  colour  in  three  or  four  days.  In  a  higher 
degree,  the  yellowness  may  extend  to  the  belly  and  upper  arms.     The  con- 


716  DISEASE  IjST   CHILDEEN". 

junetivEe  are  3-ellow  ;  the  mine  is  Mgli-colourecl,  and  stains  the  linen  ;  but 
even  in  this  case,  the  stools  may  retain  their  normal  tint,  which  at  this  age 
is  naturally  a  golden  yellow  colour.  In  this  degree,  the  symptoms  gener- 
ally last  a  week.  In  other  cases,  the  jaundice  is  general,  and  may  involve 
even  the  hands  and  feet.  The  ru'ine  is  then  distinctly  icteric  ;  the  con- 
junctivae are  very  yeUow  ;  the  tears  are  tinted,  "uith  bile,  and  the  stools  are 
clay-coloui'ed.  In  some  cases,  Seux  has  noticed  an  ophthalmia  to  come  on 
a  few  days  after  the  onset  of  the  jaundice,  with  a  copious  and  deeply- 
stained  purulent  secretion.  As  a  rule,  the  child  seems  to  suffer  little  in- 
convenience from  his  derangement.  He  takes  his  food  well  and  has  no 
23ain.  Often,  on  palpation  of  the  belly,  the  liver  will  be  noticed  to  be  in- 
creased in  size,  and  the  lower  border  may  be  felt  at  the  level  of  the  um- 
bilicus. It  is  curious  that,  although  the  mine  is  coloured  yellow,  the  most 
careful  examination  of  the  water  is  unable  to  detect  the  presence  of  bili- 
phsein.  1SD>L  Pari'ot  and  A.  Eobin  have,  however,  discovered  in  the  ic- 
teric tuine  yellow  amorj)hous  ii-regular  masses,  varying  in  size  fi'om  a  red 
blood-coi-puscle  to  a  vesical  epithelium,  and  diffeiing  in  chemical  tests 
from  the  coloruing  matter  of  the  bile.  They  have  also  noticed  the  pres- 
ence of  sediments  containing  uric  acid,  urate  of  soda,  and  oxalate  of  lime  ; 
hyaHne,  epithelial,  and  fatty  cylinders  ;  white  globules,  and  cells  fi'om  the 
lu'inary  passages. 

"When  death  occui's  in  infants  who  suffer  fi'om  this  benign  form  of 
jaundice,  the  fatal  termination  is  owing  usually  to  other  causes.  There  is 
a  variety  of  the  complaint,  to  which  attention  has  been  directed  by  Seux, 
where  the  icterus  is  accompanied  by  all  the  symptoms  of  intestinal  catarrh 
• — diarrhoea,  a  quick  pulse,  and  some  heat  and  tenderness  of  the  belly. 
There  is,  however,  rarely  vomiting.  In  the  favoiu-able  cases  the  diarrhoea 
ceases  before  the  jaundice  disappeai'S.  If  the  looseness  of  the  bowels  per- 
sists, it  is  a  dangerous  derangement  at  this  early  age,  and  the  infant  often 
dies. 

Although  usually  a  symptom  of  comparatively  little  moment,  icterus 
neonatorum  may  be  the  indication  of  very  serious  disease.  The  grave  form 
of  jaundice  may  be  the  result  of  thi'ee  different  conditions.  There  may  be 
a  congenital  malformation  of  the  gall-ducts  ;  the  ducts  may  be  compressed 
by  syphilitic  inflammation  and  gTowth  (the  syphihtic  peripylephlebitis  of 
Schiippel)  ;  or  the  icterus  may  be  the  consequence  of  umbilical  j)hlebitis 
and  pyaemia. 

Infantile  jaundice  fi-om  atresia  of  the  bile-ducts  is  fortunately  not  a 
common  disease.  Several  varieties  of  malformation  have  been  recorded : 
the  gall-duct  has  been  found  converted  into  a  fibrous  cord ;  the  common 
duct  has  been  known  to  be  obhterated,  or  absent,  or  excessively  naiTowed  ; 
sometimes  all  the  ducts  have  been  wanting  ;  in  other  cases,  the  gall-bladder 
has  been  radimentaiw  and  the  ducts  absent.  The  hver  itself  is"  normal  in 
appearance,  or  gxeatly  enlarged  ;  usually,  it  is  of  a  deejD  ohve  or  nearly 
black  colour'.  It  has  also  been  noticed  to  be  cirrhotic,  and  its  substance 
has  been  found  to  be  denser  than  natur'al.  The  microscope  shows  an 
overgTowth  of  the  areolar  tissue,  chiefly  in  the  capsule  of  Ghsson  ;  and 
broad  bands  of  connective  tissue  siuTOund  the  dark  green  islets  of  liver- 
cells.  This  incipient  cirrhosis  appears  to  be  a  constant  accompaniment  of 
obHteration  of  the  bile-ducts,  and  continues  to  advance  as  long  as  the 
child  survives.  In  animals,  hgatru-e  of  the  ducts  has  been  shown  by  Dr. 
Wickham  Legg  to  lead  to  mai'ked  hepatic  cirrhosis  and  consequent  portal 
congestion. 

This  rare  and  distressins:  form  of  malformation  is  sometimes  found  to 


JAUNDICE — CASSATION.  717 

affect  several  children  of  the  same  parents.  This  tendency  to  appear  in 
successive  children  of  the  same  family  was  noticed  by  Cheyne  in  1801, 
and  has  been  commented  upon  by  other  writers.  The  jaundice  to  which 
retention  of  the  secreted  bile  gives  rise  may  be  present  at  birth,  but  usually 
is  not  visible  before  a  week,  a  fortnight,  or  even  longer.  When  it  first 
appears,  the  discolouration  has  a  faint  yellow  tint,  but  the  colour  gets 
quickly  darker.  The  conjunctivae  are  yellow ;  the  stools  soon  become 
colourless  and  offensive  ;  and  the  urine  is  high-coloured  and  leaves  yellow 
or  greenish  brown  stains  on  the  diaper.  At  first,  nothing  abnormal  is 
noticed  about  the  belly  ;  but  after  a  day  or  two  the  liver  begins  to  enlarge, 
and  may  reach  a  great  size  in  a  short  time.  The  spleen  may  be  also  felt 
to  be  larger  than  natural.  There  is  some  swelling  of  the  belly,  and  ascites 
may  be  present  ;  but  the  abdominal  distention  is  usually  due  to  the  in- 
crease in  size  of  the  hepatic  and  splenic  viscera,  and  to  flatulent  accumula- 
tion resulting  from  the  decomposition  of  food.  Dr.  Wickham  Legg  men- 
tions swelling  of  the  hfemorrhoidal  veins  among  the  occasional  symptoms. 
The  child  usually  takes  food  well,  but  wastes  quickly.  The  bowels  are 
often  costive.  The  jaundice  is  not  constant  in  degree.  The  tint  of  the 
skin  varies,  and  on  some  days  the  infant  is  much  more  deeply  stained  than 
on  others.  Before  death,  in  some  cases,  the  abnormal  colouring  almost 
completely  disappears,  as  very  little  bile  is  formed,  owing  to  the  destruction 
of  the  secreting  tissue  of  the  hver.  The  stools  do  not  always  lose  colour 
very  rapidly  ;  sometimes  for  days,  or  even  weeks,  meconium  or  coloured 
stools  may  l^e  evacuated  ;  but  the  colour  is  usually  described  as  a  dark 
green,  and  is  due  possibly  to  altered  blood. 

A  frequent  symptom  of  this  congenital  defect  which  demands  especial 
attention,  is  haemoiThage  from  the  navel.  This  phenomenon  is  not  a  con- 
stant symptom,  but  occui's  in  the  majority  of  cases,  and  is  of  very  serious 
augury.  The  haemorrhage  generally  begins  a  few  hours  or  a  day  or  two 
after  the  fall  of  the  navel-sti'ing  (most  commonly  between  the  fifth  and  the 
ninth  day  after  birth),  and  usually  occui's  first  in  the  night.  It  is  not  a 
violent  bleeding.  Bloodc  oozes  gently  but  continuously  from  the  umbilicus. 
It  appears  to  be  capillary,  and  the  colour  ma^^  be  bright  red,  or  dark  and 
venous.  This  form  of  bleeding  may  be  combined  with  haemorrhage  from 
other  parts,  such  as  cutaneous  ecchymoses,  epistaxis,  haematemesis  or 
melaena,  and  bleeding  from  the  mouth.  The  haemorrhage,  combined  with 
the  interference  with  digestion  due  to  the  absence  of  bile  and  impaired 
action  of  the  liver,  rapidly  exhausts  the  patient ;  and  he  usually  dies  with- 
in the  week — often  in  a  few  hours.  Dr.  Legg  suggests  that  the  umbilical 
haemorrhage  is  a  consequence  of  the  cirrhosis  and  resulting  portal  conges- 
tion ;  for  the  blood  is  hindered  in  its  passage  through  the  liver,  and  is 
forced  to  seek  some  other  way  of  escape.  It  therefore  passes  from  the  left 
portal  vein  to  the  ductus  venosus,  and  thence  to  the  umbilicus,  where  the 
vessels,  newly  closed,  cannot  resist  the  increased  pressiu-e,  and  give  way.  The 
same  mechanism  (portal  congestion)  will  explain  the  frec[uent  coincidence 
of  haemorrhage  from  other  parts  supplying  the  portal  vein  with  blood. 

Cases  of  jaundice  conjoined  with  umbilical  haemorrhage  are  rapidly  fatal, 
When  this  sjonptom  is  absent,  although  the  child  almost  invariably  dies, 
life  may  be  preserved  for  a  much  longer  period.  Recorded  cases  show 
that  the  infant  may  live  five,  six,  or  seven  months,  and  even  then,  as  in 
Lotze's  case,  where  the  child  lived  into  the  beginning  of  the  eighth  month 
and  died  of  a  broncho-pneumonia,  may  succumb  to  an  accidental  compli- 
cation. This  malformation  is  said  to  be  twice  as  common  in  boys  as  it  is 
in  oirls. 


718  DISEASE  IN   CHILDEElSr. 

A  male  infant,  deeply  jaundiced,  aged  tliree  months,  was  brought  to 
the  out-patients'  room  of  the  East  London  Children's  Hospital  and  was  at 
once  admitted  by  my  colleague.  Dr.  Eadcliife  Crocker,  into  the  wards. 
The  child  was  born  of  healthy  parents,  none  of  whose  other  children  had 
been  similarly  afflicted.  He  was  said  to  have  been  a  robust,  healthy- 
looking  infant  at  birth,  and  shortly  afterwards  to  have  passed  two  dark 
stools.  Since  that  time,  however,  his  motions  had  been  hard  and  white, 
like  lumps  of  chalk,  and  the  bowels  had  acted  only  once  a  clay.  The  jaun- 
dice had  first  appeared  when  the  child  was  a  week  old,  and  had  progressively 
increased.  The  infant  had  been  suckled  for  a  month,  and  was  then  fed  on 
Swiss  milk.  He  often  vomited,  not  always  after  taking  food,  and  was 
capricious  about  his  bottle,  sometimes  refusing  to  suck.  His  water  had 
always  been  dark,  leaving  yellow  stains  on  the  diaper. 

When  admitted,  the  child  was  fairly  nourished.  His  skin  was  deeply 
jaundiced,  and  his  conjunctivae  were  yellow.  There  was  a  papular  eruption 
(strophulus)  all  over  his  body.  The  liver  could  not  be  felt  at  this  time  on 
account  of  the  child's  struggles,  but  was  found  a  few  days  afterwards  to 
project  two  fingers'  breadths  below  the  ribs.  The  bo}'  lived  a  month  after 
his  admission,  wasting  gradually,  and  often  crying  as  if  in  pain.  Then 
aphthae  appeared  in  his  mouth,  and  he  sank  and  died.  There  were  no 
haemorrhages.  His  jaundice  persisted,  although  it  varied  curiously  in  in- 
tensity ;  and  before  his  death  the  tint  of  the  skm  was  several  shades  Hghter 
than  when  he  entered  the  hospital.  The  liver  remained  about  the  same 
size  and  felt  firm  and  smooth.  The  spleen  was  not  enlarged.  After  death 
the  liver  was  found  of  a  dark  olive  colour,  and  its  consistence  seemed  to 
be  increased.  The  gall-bladder  was  rudimentary,  and  the  hepatic  and 
common  ducts  were  absent. 

When  syphilitic  infiammation  of  the  liver  gives  rise  to  jaundice,  the  or- 
gan is  enlarged  and  deeply  coloured  of  a  brownish  yellow  tint,  and  shows 
under  the  microscope  a  great  proliferation  of  young  cells  in  the  capsule  of 
Glisson,  and  in  the  interlobular  spaces.  In  a  case  recorded  by  M.  D'Espine, 
of  Geneva,  the  same  proliferation  was  noted  round  the  hepatic  cells  in  the 
interior  of  the  lobules.  Moreover,  the  small  bile-ducts  were  thickened 
and  filled  with  epithelial  cells.  There  was  no  obstruction  in  the  larger 
ducts,  and  the  gall-bladder  contained  thick  and  dark-coloured  bile.  The 
spleen  was  greatly  enlarged  and  very  firm. 

In  this  case  the  jaundice  was  severe  and  appeared  at  birth.  On  the 
ninth  day  bleeding  occurred  from  the  umbilicus,  from  the  bowels,  and  into 
the  skin  ;  the  belly  swelled  ;  the  liver  and  spleen  were  notably  enlarged  ; 
the  temperature  became  subnormal ;  the  child  wasted  rapidly,  and  died  on 
the  twenty-third  day  in  convulsions. 

SdMXidice  irom.  iimhilical plilebitiii'h.QS.heQxi  called  by  Sch tiller  "icterus 
malignus."  This  variety  appears  to  be  dependent  upon  an  infective  pro- 
cess. The  poisonous  matter  is  probably  the  same  as  that  which  causes 
puerperal  fever  in  the  mother,  and  ma}^  be  conveyed  by  bacteria,  for  two 
forms  of  micro-organisms  have  been  found  in  the  blood  of  infants  so 
affected,  the  one  spherical  and  the  other  rod-shaped.  Whether  these 
two  different  forms  imply  two  different  kinds  of  infection  is  not  known, 
but  Birch-Hirschfeld  asserts  that  the  rod-shaped  bacteria  are  especially 
observed  in  cases  where  the  general  infection  is  severe  and  the  disease 
violent  from  the  first,  with  a  strong  tendency  to  haemorrhage.  These 
cases  are  accompanied  by  inflammation  of  the  umbilical  artery,  with  or 
without  phlebitis  of  the  umbilical  vein.  In  sixty  cases  collected  by  this 
observer,  umbilical  arteritis  was  found  in  thirty- two,  umbilical  phlebitis 


JAUNDICE — DIAG]SrOSIS.  719 

in  eleven,  and  inflammation  of  both  vessels  in  three.  An  examination  of 
the  liver  reveals  profound  degeneration.  These  changes  seem  to  indicate 
that  the  infection  must  reach  the  Hver  by  the  umbilical  vein.  They  may, 
however,  be  found  in  cases  where  the  artery  alone  is  notably  diseased  ; 
but  there  are  reasons  why  the  morbid  appearances  should  be  more  con- 
spicuous in  the  umbiHcal  artery.  After  birth,  the  remnant  of  the  umbiHcal 
vein  is  alternately  emptied  and  filled  again  on  account  of  the  varying 
pressure  on  the  hepatic  vessels  induced  by  the  action  of  the  heart  and 
lungs.  This  constant  flux  and  reflux  in  the  vein  tends  to  promote  infec- 
tion of  the  system,  but  is  unfavourable  to  the  local  development  of  the 
morbid  process.  It  is  found  in  these  cases  that  the  intensity  of  the  jaun- 
dice bears  no  relation  to  the  severity  of  the  vascular  inflammation,  but  that 
it  is  in  direct  proportion  to  the  degree  to  which  the  pathological  changes 
have  advanced  in  the  hver.  It  is  probably,  therefore,  the  consequence  of 
the  swelling  of  the  connective  tissue  surrounding  the  portal  vein  and  its 
branches  in  the  hver,  which  compresses  the  bile-ducts. 

In  these  cases,  the  jaundice  comes  on  a  few  days  after  birth,  and  by  the 
end  of  the  week  is  weU  marked.  The  urine  is  intensely  yellow ;  but 
the  stools  may  be  of  normal  tint,  although  usually  costive.  The  onset  of 
the  jaundice  is  accompanied  or  quickly  followed  by  fever,  which  soon  be- 
comes high.  There  is  often  vomiting  of  yellow  or  greenish  matter.  The 
child  looks  excessively  ill.  His  face  is  livid,  with  pinched,  haggard  features, 
and  he  refuses  the  bottle  or  the  breast.  His  tongue  is  dry ;  his  hands 
and  feet  are  purple  ;  his  abdomen  swells  and  is  tender  ;  fluctuation,  more 
or  less  distinct,  is  noticed  ;  and  blood  or  blood-stained  pus  oozes  from  the 
navel.  Sometimes  the  spleen  enlarges,  and  petechise  are  noticed  on  the 
skin.     Death  may  be  preceded  by  convulsions  and  coma. 

When  jaundice  occurs  after  the  age  of  infancy,  it  is  due  to  the  same 
causes  which  give  rise  to  the  symptom  in  the  adult.  Of  these,  no  doubt, 
duodenal  catarrh  extending  into  the  bile-ducts  is,  of  all  others,  the  most 
frequent.  On  this  account,  the  symptom  is  usually  a  trifling  one,  and  is 
quickly  recovered  from.  It  is  accompanied  by  some  temporary  enlarge- 
ment of  the  liver,  which  can  be  felt  to  project  several  fijigers'  breadths  be- 
low the  ribs  ;  but  except  for  some  delicacy  of  digestion,  httle  discomfort  is 
experienced.  In  exceptional  cases,  the  derangement  may  be  the  conse- 
quence of  plugging  of  the  common  duct  with  inspissated  bile,  and  this 
accident  has  been  noticed  in  an  infant  of  thi-ee  months  old.  Again,  a 
lumbricus  has  been  known  to  penetrate  into  the  common  duct  and  produce 
such  impediment  to  the  flow  of  bile  as  to  give  rise  to  jaundice.  Icterus 
may  be  also  due  to  acute  yellow  atrophy  of  the  hver  ;  but  this  is  fortunately 
a  very  rare  disease  in  childhood.  Of  other  causes,  atrophic  cirrhosis  of  the 
liver,  phosphorus  poisoning,  and  miasmatic  influences  have  been  recorded 
as  producing  jaundice  in  early  life. 

Diagnosis. — ^In  examining  a  new-born  infant  for  signs  of  jaundice,  it  is 
often  necessaiy  to  force  the  blood  out  of  the  skin  by  firm  pressui'e  vnth 
the  fijiger  before  the  natural  tint  of  the  integument  can  be  observed.  In 
inspecting  the  eyes  for  yellow  staining  it  is  advisable  to  use  no  force  in 
attempting  to  open  the  lids  with  the  finger,  but  rather  to  wait  until  the 
child  opens  his  eyes  spontaneously.  A  baby,  when  the  eyelids  are  touched, 
squeezes  them  together  instinctively.  In  such  a  case  oui"  utmost  efforts 
will  often  succeed  only  in  exposing  the  palpebral  mucous  membrane,  and 
this  will  quite  conceal  the  globe  of  the  eye  from  view. 

The  diagnosis  between  false  jaundice  and  true  icterus  neonatorum,  if 
the  lattej!"  "b<ei  of  the  benign  variety  and  little  pronounced,  is  very  difficult — 


720  DISEASE  IE"   CHILDEEN. 

often  quite  impossible.  In  neither  case  is  the  conjunctiva  stained  or  the 
mine  yellow.  The  colour  will  sometimes  help  us,  for  the  tint  of  the  jaun- 
diced skin  is  often  more  distinctly  yellow  than  the  brownish  stain  left 
after  severe  cutaneous  congestion.  In  all  cases  where  the  conjunctivae  and 
urine  are  tinted,  however  slightly,  we  may  conclude  that  the  case  is  one  of 
true  jaundice.  The  condition  of  the  stools  is  of  less  moment,  for  jaundice 
may  be  present  without  the  motions  being  clay-coloured. 

In  cases  where  the  jaundice  persists  and  becomes  deeper  and  deeper, 
we  have  every  reason  to  suspect  the  existence  of  some  congenital  mal- 
formation, especially  if  a  previous  child  of  the  same  parents  has  died 
shortly  after  birth  with  symptoms  of  icterus  neonatorum.  If  the  liver  and 
spleen  become  enlarged,  the  temperature  remaining  low,  this  suspicion 
becomes  almost  a  certainty  ;  and  the  occurrence  of  bleeding  from  the  navel 
is,  in  such  a  case,  practically  conclusive.  The  partial  disappearance  of  the 
jaundice  is  no  proof  that  our  apprehensions  are  unfounded,  for  the  yeUow 
tint  of  the  skin  may  become  distinctly  hghter,  or  even  quite  disappear  be- 
fore the  end. 

The  pycemic  form  of  jaundice  is  readily  detected.  The  general  appear- 
ance of  the  child,  the  high  temperature,  the  dry  tongue,  the  swelling  and 
tenderness  of  the  belly,  the  discharge  of  Iblood  and  pus  from  the  umbihcus, 
and  the  early  death,  sufficiently  indicate  the  nature  of  the  disease. 

If  the  jaundice  is  accompanied  by  signs  of  inherited  syphilis,  or  if, 
without  these,  we  can  discover  a  history  of  syphilis  in  the  father,  or  of 
previous  miscarriages  on  the  part  of  the  mother,  the  probability  of  a 
syphilitic  origin  to  the  jaundice  must  be  taken  into  consideration. 

Prognosis. — So  long  as  the  jaundice  is  accompanied  by  no  signs  of 
discomfort,  little  anxiety  need  be  excited  by  the  symptom  ;  but  if  diarrhoea 
or  vomiting  occur,  the  injurious  effect  of  exhausting  discharges  upon  a 
newly  born  infant  must  not  be  overlooked.  Little  information  is  to  be 
gained  by  inspection  of  the  stools,  for  in  cases  of  serious  malformation 
they  may  remain  normal  in  appearance  for  a  considerable  time.  If,  in  any 
case,  the  motions  become  clay-coloured,  and  the  staining  of  the  skin  and 
urine  shows  no  sign  of  subsiding,  there  is  cause  for  apprehension.  A 
slight  enlargement  of  the  liver  [i.e.,  a  pi-ojection  of  one  finger's  breadth 
below  the  ribs)  is  immaterial ;  but  if  the  organ  continue  to  increase  in  size, 
and  if  the  spleen  also  begin  to  swell,  the  infant's  condition  is  becoming  a 
serious  one.  It  must  not  be  forgotten  in  these  cases  to  examine  the  anus  ; 
for  the  appearance  of  any  swelling  of  the  hsemorrhoidal  veins,  as  indicating 
great  obstruction  to  the  portal  circulation,  is  an  unfavourable  symptom  of 
no  little  importance. 

If  we  are  satisfied  that  the  case  is  one  of  congenital  deficiency  or  mal- 
formation, we  can  have  little  hope  of  a  favourable  issue,  although  life  may 
be  prolonged  for  several  months.  The  appearance  of  umbilical  hsemorrhage 
is  a  very  fatal  sign,  and  is  usually  followed  by  rapid  sinking  of  the  patient. 

If  the  jaundice  is  due  to  syphilitic  disease,  it  is  hardly  likely  to  end 
otherwise  than  unfavourably ;  and  in  cases  of  umbilical  phlebitis  and 
pyaemia,  we  can  hold  out  no  hope  of  recovery. 

In  older  children,  icterus,  unless  it  be  due  to  phosphorus  poisoning  or 
some  profotmd  hepatic  lesion,  is  in  most  cases  a  mild  derangement  which 
soon  passes  away. 

Treatment. — Ordinary  benign  jaundice  in  the  new-born  baby  requires 
little  treatment.  Emetics,  although  strongly  recommended  by  some  wi'iters, 
are  in  most  cases  useless,  if  not  injurious.  A  gentle  purge,  such  as  castor- 
oil,  followed  by  two  or  three  grains  of  bicarbonate  of  soda  with  a  quarter 


JAUNDICE — TREATMENT.  721 

of  a  drop  of  tincture  of  nux  vomica,  given  three  times  a  day,  will  soon 
restore  the  child's  tissues  to  their  natural  colour.  I  now  invariably  give  nux 
vomica  with  an  alkali  in  these  cases,  and  beUeve  that  in  catarrhal  jaundice 
at  all  ages  the  former  drug  has  a  distinct  influence  in  aiding  the  child's 
recovery.  If  pui'gatives  are  prescribed,  the  aperients  used  should  be  those 
which,  like  castor-oil  or  aloes,  act  low  down  in  the  alimentary  canal.  Senna 
and  other  drugs  which  influence  the  duodenum  and  upper  part  of  the 
bowels  may  increase  the  irritation  of  this  part  of  the  intestine,  and  are 
unsuitable  to  cases  of  jaundice — at  any  rate  to  those  cases  where  there  is 
reason  to  suspect  the  existence  of  duodenal  catarrh.  Mercurials,  too, 
should  be  given  with  judgment.  It  is  not  advisable  to  continue  acting 
upon  the  liver  by  repeated  doses  of  mercury.  One  dose  of  gray  powder 
or  of  calomel  may  be  allowed,  but  the  remedy  need  not  be  afterwards  re- 
peated. "With  regard  to  diet : — The  infant  may  stiU  continue  to  take  the 
breast.  If  he  be  bottle-fed,  no  alteration  need  be  made  in  his  food  unless 
vomiting  occur  with  signs  of  acid  fermentation.  If  these  symptoms  of 
gastric  catarrh  are  noted,  the  diet  must  be  regulated  according  to  the  rules 
laid  down  in  the  chapter  on  Infantile  Atrophy. 

If  the  jaundice  be  due  to  malformation,  no  treatment  can  be  expected 
to  be  of  service  ;  but  if  haemorrhage  occur  from  the  navel,  attempts  should 
be  made  to  arrest  a  symptom  which  experience  has  proved  to  be  so  speed- 
ily fatal.  The  perchloride  of  iron  may  be  used  locally,  followed  by  a  com- 
press ;  but  in  most  cases,  the  svirgeon  has  to  fall  back  upon  the  operation 
known  as  the  "  ligature  en  masse."  The  child  should  be  laid  upon  his  back, 
and  two  hare-lip  pins  must  be  passed  through  the  integuments  at  the  root 
of  the  navel,  carefuUy  avoiding  the  peritoneum.  A  ligature  is  then  twisted 
tightly  round  the  needles  in  the  form  of  a  figure  of  eight. 

If  syphilis  be  present  in  the  child,  treatment  for  this  constitutional  con- 
dition should  be  adopted  without  loss  of  time.  In  cases  of  pysemic  jaun- 
dice, attempts  must  be  made  to  relieve  the  distressing  symptoms.  Warmth 
should  be  apphed  to  the  beUy ;  and  if  there  is  great  tenderness  about  the 
umbilicus,  extract  of  belladonna  diluted  with  an  equal  quantity  of  glycerine, 
can  be  applied  to  the  skin  round  the  navel.  Stimulants  must  be  given  as 
required. 

46 


CHAPTER  n. 

CONGESTION  OF  THE  LIVER. 

Congestion  of  the  liver,  although  a  common  derangement  in  the  child, 
is  yet  often  suspected  when  not  actually  present.  Many  symptoms  attrib- 
uted to  a  "torpid,"  "inactive,"  or  congested  liver,  and  treated  with  gTay 
powder,  are  really  due  to  a  disordered  state  of  the  stomach  dependent  upon 
an  improper  dietary,  and  may  be  readily  relieved  by  the  exercise  of  a  little 
judgment  in  the  child's  food  and  general  management.  A  liver  morbidly 
congested  gives  rise  to  a  very  definite  group  of  symptoms,  as  will  be  after- 
wards described. 

Causation. — The  amount  of  blood  circulating  in  the  liver  may  vary  con- 
siderably within  normal  hmits.  During  digestion  it  is  increased  for  the 
time  ;  and  if  the  child  be  habitually  overfed,  or  be  frequently  indulged 
w^ith  highly  spiced  and  stimulating  food,  the  hypersemia  lasts  longer  and  is 
more  intense  than  if  he  eat  more  moderately  or  of  a  plainer  diet.  Want  of 
exercise  and  too  close  confinement  to  the  house  will  increase  the  injurious 
effects  of  this  unwholesome  regimen.  The  other  principal  causes  of  morr 
bid  congestion  of  the  liver  are : — Any  cause  which  interferes  with  the  return 
of  blood  from  the  Uver.  The  commonest  of  these  is  disease  of  the  heart 
interfering  with  the  return  of  blood  from  the  lungs.  The  pulmonary  cir- 
culation suffers  primarily ;  and  secondarily,  the  impediment  spreads  to  the 
vena  cava  and  the  portal  vein.  Congestion  of  the  hver  is  also  a  consequence 
of  the  ague  poison,  for  malarial  fever  is  as  common  a  cause  of  hepatic  con- 
gestion as  it  is  of  splenic  enlargement,  and  a  swollen  hj^ereemic  liver  is  a 
familiar  symptom  in  tropical  climates.  Again,  chilhng  of  the  surface  is  one 
of  the  most  frequent  agents  in  the  production  of  liver  congestion,  and  en- 
largement of  the  organ  from  this  cause  is  a  usual  accompaniment  of  ca- 
tarrhal jaundice. 

Morbid  Anatomy.— A.  congested  liver  is  enlarged  in  all  directions,  and  is 
very  thick ;  its  resistance  is  increased,  and  the  peritoneal  coat  is  tense  and 
shining.  When  cut  into,  the  organ  'bleeds  freely,  and  the  section  shows  a 
spotted  or  "  nutmeg  "  surface  from  dilatation  of  the  intra-lobular  veins.  Of- 
ten, the  colour  of  the  parenchyma  surrounding  the  central  vein  of  the  lobule 
is  yellowish  from  interference  with  the  escape  of  bile  from  the  ducts ;  for 
jaundice  is  not  unfrequently  associated  with  this  hepatic  congestion. 

If  the  hypersemia  of  the  organ  is  a  chronic  condition,  further  changes 
take  place  after  a  time.  The  enlargement  of  the  intra-lobular  hepatic  veins 
induces  atrophy  of  the  liver-cells  in  their  immediate  neighbourhood.  Sur- 
rounding these  cells  are  others  which  are  stained  deeply  with  bile,  and  at 
the  cu'cumference  of  the  lobule  the  cells  are  often  filled  with  oil.  The 
atrophied  cells  may  completely  disappear ;  and  eventually  a  new  formation 
of  fibroid  tissue  takes  place  in  connection  with  the  inter-lobular  vessels. 
The  fibroid  gTowth  shrinks,  and  a  condition  akin  to  cirrhosis  is  set  up  ;  the 
organ  becoming  granidar  on  the  surface  and  the  capsule  thickened. 


CONGESTION   OF   THE   LIVER — SYMPTOMS — DIAGNOSIS.       723 

Symptoms. — If  the  liver  be  much  congested,  we  generally  find  that  there 
is  some  pain  in  the  right  hypochondriac  region ;  that  it  is  tender  when 
pressed  ;  and  that  coughing  or  a  deep  inspiration  is  distressing.  The  child 
is  often  unwilling  to  lie  on  either  side — on  the  right  because  of  the  direct 
pressiu'e  ;  on  the  left  because  of  the  weight  of  the  congested  organ  causing 
an  uneasy  dragging  sensation.  On  palpation  of  the  belly,  the  edge  of  the 
liver  is  felt  several  fingers'  breadths  below  the  ribs,  and  on  percussion  we 
generally  find  that  the  upper  limit  of  dulness,  instead  of  beginning  in  the 
fourth  interspace,  begins  in  the  third  or  on  the  third  rib.  Sometimes,  es- 
pecially if  there  is  jaundice,  the  distended  gall-bladder  can  be  felt  as  a  pear- 
shaped  tumour  below  the  inferior  edge  of  the  Uver. 

Dyspeptic  symptoms  from  hyperaemia  of  the  gastric  vessels  generally  ac- 
company a  congested  liver.  The  tongue  is  furred  ;  there  may  be  headache ; 
nausea  may  be  complained  of ;  the  bowels  may  be  relaxed,  and  the  stools 
light-coloured  and  offensive.  The  urine  is  dark,  and  may  throw  down  a 
copious  deposit  of  lithates.  The  skin  is  often  sallow ;  and  if  the  conges- 
tion be  accompanied  by  duodenal  catarrh,  there  will  probably  be  jaundice. 

If  the  congestion  is  due  to  cardiac  disease  the  child  is  harassed  with 
dyspnoea  and  cough  from  interference  with  the  pulmonaiy  circulation  ;  his 
digestion  is  deranged,  and  there  is  often,  in  addition,  oedema  of  the  lower 
Hmbs,  with  albuminuria. 

A  congested  liver  is,  as  has  been  said,  frequent  in  cases  of  ague. 
Often,  until  this  condition  is  remedied,  quinine  has  but  little  influence  over 
the  attacks.     This  subject  is  discussed  elsewhere  (see  Ague). 

Diagnosis. — A  congested  liver  is  increased  in  size,  and  pressure  upon 
it  produces  some  uneasiness.  Mere  light-coloured  offensive  stools  are  not 
in  themselves  a  sign  of  hepatic  hypersemia.  It  is  common  for  a  child  who 
is  being  fed  upon  large  quantities  of  farinaceous  food,  or  who,  owing  to  a 
catarrhal  condition  of  his  stomach  and  bowels,  is  for  the  time  incapable  of 
digesting  a  milk  diet,  to  evacuate  more  or  less  semi-solid  pasty  or  putty- 
like matter  from  the  bowels.  But  the  stools  in  such  a  case  consist  of  un- 
digested food,  and  are  not  indicative  of  arrested  biliai'y  secretion.  If  such 
a  condition  be  treated,  as  it  often  is,  by  repeated  doses  of  gray  powder  or 
other  form  of  mercurial,  the  aperient  action  of  the  medicine  produces  on 
each  occasion  a  dark  biliary  stool,  but  the  effect  of  the  drug  having  passed 
off,  the  evacuations  continue  to  be  as  pasty  as  they  were  before.  This  con- 
dition, as  is  elsewhere  explained,  must  be  treated,  not  by  cholagogues,  but  by 
measures  which  rectify  the  gastric  and  intestinal  derangement  (see  p.  640). 

To  justify  the  diagnosis  of  hepatic  congestion  we  must  require  enlarge- 
ment and  tenderness  of  the  liver  and  a  sallow  complexion,  as  well  as  diges- 
tive disturbance  and  light-coloured  stools.  We  must  not,  however,  con- 
clude too  hastily  that  the  size  of  the  liver  is  abnormal.  The  organ  is  apt 
to  vary  in  size  in  young  subjects  from  natural  causes,  and  in  some  children 
whose  chests  are  exceptionally  short  may  project  for  a  finger's  breadth  or 
so  below  the  ribs  without  being  congested  or  otherwise  diseased.  Be- 
sides, it  is  important  not  to  mistake  a  liver  merely  displaced  for  a  liver 
morbidly  enlarged.  The  organ  may  be  pushed  down  by  fluid  accumulation 
in  the  pleura,  or  by  emphysema  of  the  lung  ;  and  I  have  ]i:nown  an  exten- 
sive pericardial  effusion  to  produce  the  same  effect.  In  rickety  children 
with  deeply  grooved  chests,  the  liver  and  spleen,  although  not  enlarged, 
may  be  felt  more  distinctly  than  natural,  being  forced  downwards  some- 
what from  their  original  position.  It  is  therefore  important  to  ascertain 
by  percussion  the  upper  limits  of  the  liver  dulness  as  well  as  the  exact 
level  of  the  inferior  margin.      Again,  a  liver,  although  enlarged,  may  lie 


724  DISEASE  IlSr   CHILDEElSr. 

completely  under  cover  of  the  ribs,  and  its  abnormal  condition  may  thus 
escape  notice.  It  may  be  pushed  upwards  by  fluid  accumulation  and 
growth  in  the  belly  ;  or  may  be  placed  higher  than  it  otherwise  woidd  be 
through  the  shrinking  in  the  chest  of  a  collapsed  or  indurated  lung. 
Therefore,  in  an  examination  of  the  organ,  we  must  remember  these  sources 
of  eiTor,  and  ascertain  all  its  limits  before  coming  to  a  conclusion. 

A  good  example  of  a  congested  hver  is  seen  in  the  following  case :  A 
little  boy,  aged  three  years,  of  healthy  parentage,  was  brought  to  the  East 
London  Children's  Hospital  with  the  histoiy  that  for  five  weeks  he  had 
been  noticed  to  be  languid  and  chilly,  with  little  appetite  and  with  some 
swelling  and  tenderness  of  his  belly.  The  bowels  had  acted  two  or  three 
times  a  day,  the  motions  being  hght-coloured,  thin,  and  scanty.  The  child 
was  restless  and  fretful,  sleeping  uneasily,  and  often  starting  and  twitch- 
ing in  his  sleep. 

The  boy  was  the  subject  of  moderate  rickets.  His  ribs  were  beaded, 
the  ends  of  his  long  bones  large,  and  his  chest  was  flattened  laterally.  He 
had  cut  all  his  teeth  and  his  fontanelle  was  closed.  The  skin  was  harsh 
and  dry,  and  was  tinted  all  over  the  body  of  an  earthy  yellow  colour. 
The  belly  was  large,  and  the  lower  edge  of  the  hver  reached  to  nearly  the 
level  of  the  umbilicus.  Its  substance  was  natural,  without  any  increase  in 
firmness.     Its  edge  was  not  thickened.     The  spleen  could  not  be  felt. 

The  patient  was  treated  with  mercurial  purges  followed  by  salines,  and 
an  alkah  with  bitter  infusion  was  given  to  him  three  times  a  day.  In  a 
fortnight  after  this  treatment  had  been  begun,  the  hver  had  become  much 
reduced  in  size.  Its  ujDper  border  was  at  the  fifth  rib,  and  its  lower  bor- 
der could  be  felt  two  fingers'  breadths  below  the  ribs.  It  was  evidently 
pushed  downwards  by  the  rickety  deformity  of  the  chest,  and  was  no 
doubt  now  of  natural  size.  As  the  hver  became  smaller,  the  child's  ap- 
petite improved  ;  his  skin  lost  its  earthy  yellow  tint,  and  the  colour  and  con- 
sistence of  the  stools  became  natural. 

In  this  case,  all  the  symptoms  pointed  to  congestion  of  the  liver  ;  and 
palpation  of  the  beUy  detected  enlargement  of  the  organ  without  any  al- 
teration in  its  consistence. 

In  warm  climates,  it  is  important  to  exclude  hepatitis.  In  suppurative 
inflammation  of  the  liver,  the  pain  and  tenderness  are  greater  than  if  the 
liver  be  merely  congested  ;  the  general  disturbance,  although  considering 
the  serious  nature  of  the  disease  jproportionately  slight,  is  greater  ;  the 
child  looks  ill,  which  is  not  the  case  in  uncomplicated  congestion,  and 
there  is  fever. 

Prognosis. — Congestion  of  the  hver  is  in  itself  a  trifling  ailment.  Any 
danger  connected  with  the  case  is  dependent  upon  the  general  condition 
of  the  child,  or  the  existence  of  serious  disease  of  a  vital  organ. 

Treatment. — If  the  congestion  is  dependent  upon  overfeeding  and  in- 
sufficient exercise,  we  should  be  careful  to  regulate  the  diet,  and  allow  only 
food  which  is  digestible  and  unstimulating  as  well  as  moderate  in  quantity. 
The  child  should  be  restricted  for  a  day  or  two  to  bread  and  milk  with 
mutton-broth  or  a  little  boiled  fish  for  his  dinner.  His  belly  should  be 
protected  by  a  flannel  band,  and  the  action  of  the  skin  should  be  promoted 
by  a  warm  bath  before  going  to  bed.  The  medicinal  treatment  should 
begin  with  a  few  grains  of  gray  powder  combined  with  half  a  gi'ain  of 
powdered  ipecacuanha  and  two  to  five  of  jalapine.  This  should  be  given 
at  bedtime,  and  in  the  morning  the  child  may  take  a  dose  of  Kquid 
magnesia  or  other  saline  aperient.  Remedies  which  act  upon  the  skin 
and  kidneys  are  useful  in  these  cases.     We  may  give  two  or  three  times  a 


CONGESTION   OF   THE   LIVER — TREATMENT.  725 

day  a  mixture  composed  of  solution  of  acetate  of  ammonia,  sweet  spirits  of 
nitre,  and  a  few  grains  of  the  bicarbonate  of  soda  or  potash.  Chloride  of 
ammonium  (gr.  iij.  to  gr.  vj.)  is  also  recommended.  It  may  be  made 
palatable  by  extract  of  Hquorice,  chloric  ether,  and  glycerine. 

The  same  treatment  is  useful  if  the  hepatic  congestion  can  be  attributed 
to  a  chill.  In  these  cases,  especially  if  there  is  jaundice,  we  should  be 
careful  not  to  employ  senna  and  other  purgative  drugs  which  act  principally 
upon  the  upper  part  of  the  intestinal  canal,  in  order  not  to  increase  the 
irritation  of  the  duodenum  ;  but  should  keep  the  bowels  regular  by  aloes 
or  the  saline  aperients. 

If  the  congestion  of  the  liver  occur  as  a  consequence  of  heart  disease, 
it  wiU  be  relieved  by  measures  directed  to  strengthen  the  cardiac  action 
and  lessen  the  general  hypersemia  from  which  the  patient  is  suffering.  If 
it  arise  in  the  course  of  an  attack  of  malarial  fever,  it  must  be  reduced  as 
rapidly  as  possible  by  sahne  and  mercurial  purges  (see  Ague). 

Children  who  are  habitually  indulged  and  injudiciously  fed,  especially 
if  they  are  accustomed  to  warm  stuffy  rooms,  may  suffer  from  frequent 
attacks  of  hepatic  congestion,  and  their  livers  may  seem  to  be  permanently 
enlarged.  In  such  cases,  it  is  useful  to  send  them  to  a  watering-place 
where  they  can  drink  regularly  of  some  natural  saline  aperient,  and  take 
daily  and  sufficient  exercise  in  the  open  air.  After  a  short  course  of  the 
waters,  iron  and  quinine  can  be  given  with  benefit. 


CHAPTER  III. 

CIRRHOSIS   OP   THE   LIVER. 

CiBEHosis  of  the  liver,  although  not  one  of  the  more  common  diseases  in 
the  child,  cannot  be  said  to  be  very  rare.  In  some  children,  even  at  a 
very  early  age,  there  appears  to  be  a  peculiar  tendency  to  the  formation 
and  proliferation  of  fibroid  tissue.  Sometimes  the  fibroid  overgrowth  is  a 
general  one ;  sometimes  it  is  more  local,  and  is  hmited  to  particular  organs 
— the  lungs,  the  liver,  or  the  kidneys.  Fibroid  induration  of  the  Itmgs 
occurring  as  a -result  of  catarrhal  pneumonia  and  pleurisy,  is  a  sufficiently 
famihar  experience  ;  but  a  similar  pathological  change  in  other  internal 
organs  is  much  less  frequently  met  with. 

Causation. — The  causes  of  hepatic  cirrhosis  in  early  hfe  are  obscure. 
Intemperance  in  alcohol,  to  which  the  disease  in  the  adult  is  usually  attrib- 
uted, is  of  course  exceptional  in  the  case  of  a  child.  It  is  possible  that, 
as  some  writers  are  disposed  to  beheve,  this  vice  may  be  one  of  the  sins  of 
the  fathers  which  are  visited  upon  their  offspring,  and  that  cirrhosis  in  the 
child  may  be  due  to  intemperance  in  the  parent ;  but  this,  at  present,  at 
any  rate,  is  no  more  than  hypothesis.  Congenital  deficiency  of  the  bile- 
ducts  is  often — always,  according  to  Dr.  "Wickham  Legg — accompanied  by 
an  early  stage  of  hepatic  cirrhosis.  SyphUis  may  sometimes  produce  it ; 
and  MM.  Cornil  and  Ranvier  have  described  an  interstitial  hepatitis  as  ac- 
companying cases  of  general  tuberculosis.  Hepatic  cirrhosis  has  been  seen 
at  a  very  early  age.  Weber  has  found  the  atrophic  form  in  a  new-born 
infant ;  and  in  cases  of  malformation  of  the  bile-ducts,  it  is  always  an  early 
change,  as  death  usually  takes  place  in  the  course  of  a  few  months.  The 
hypertrophic  form  is  sometimes,  also,  met  with  in  very  young  children. 
Wettergren  has  seen  it  in  a  boy  of  five  ;  and  Dr.  S.  West  has  reported  a 
case  in  a  boy  of  six.  It  is  curious  that  in  each  of  these  instances  the  child 
had  been  in  the  habit  of  drinking  largely  of  coffee. 

Morbid  Anatomy. — Cirrhosis  of  the  liver  may  be  atrophic  or  hypertrophic, 
and  these  two  conditions  have  very  distinct  pathological  characters. 

In  atrophic  cm'hosis  (the  hobnailed  liver,  cirrhosis  of  Laennec)  there  is 
abnormal  development  of  new  fibroid  tissue  which  permeates  the  organ,  fol- 
lowing the  branches  of  the  portal  vein.  The  new  development  apj)ears  to 
originate  in  a  chronic  inflammatory  condition  of  these  vessels.  It  produces 
great  thickenuag  of  the  capsule  of  Ghsson,  the  prolongation  of  which  en- 
velopes the  portal  branches,  and  extending  from  it  into  the  interlobular 
spaces,  forms  meshes  which  embrace  portions  of  the  hepatic  substance. 
These  portions  vary  in  size,  but  all  comprise  several  lobules.  The  process 
consists  in  a  rapid  proliferation  of  embryonic  cells  which  undergo  conver- 
sion into  cicatricial  fibroid  tissue.  After  a  time,  contraction  takes  place  in 
the  new  material,  and  the  liver  becomes  small  and  shrunken,  with  an  ir- 
regular granular  surface  and  a  dense  substance.     Its  enveloping  capsule  is 


CIEEHOSIS   OF   THE   LIVEE — MOEBID   ANATOMY — SYMPTOMS.     727 

much  thickened.  On  section,  the  surface  is  of  a  dirty  yellow  colour,  and 
is  seen  to  be  divided  into  irregular  meshes  by  the  fibrous  network. 

The  contraction  of  the  dense  interstitial  tissue  compresses  the  lobules 
so  that  the  liver-cells  become  flattened  and  atrophied,  and  causes  great  ob- 
struction to  the  portal  circulation.  Consequently,  the  whole  portal  system 
is  congested.  Its  blood,  unable  freely  to  escape,  has  to  find  a  new  channel ; 
and  a  collateral  circulation  becomes  gradually  estabhshed  by  enlargement 
of  the  principal  veins  in  the  suspensory  ligament  passing  to  the  umbiHcus. 

The  nutrition  of  the  liver,  and  the  formation  of  bile,  are  kept  up  by  the  de- 
velopment of  new  vessels,  which  permeate  the  new  fibrous  tissue  and  convey 
blood  from  the  hepatic  artery  to  the  intra-lobular  vessels.  The  smaller  bil- 
iary ducts  are  but  little  affected  by  the  changes  which  take  place,  so  that 
there  is  seldom  retention  of  bile  or  jaundice.  In  this  form  of  cii'rhosis,  the 
organ  is  somewhat  enlarged  in  the  early  stage,  but  afterwards  becomes  very 
small  and  contracted. 

In  hyjyertrophic  cirrhosis,  the  hver  is  usually  larger  than  in  health,  and 
may  be  increased  to  twice  its  natural  size.  It  is  smooth  on  the  sui-face, 
with  a  normal  thin  edge,  and  on  section,  its  substance  is  orange  yellow  or 
green  in  colour.  The  fibroid  overgrowth  in  this  case  follows  the  ramifica- 
tions of  the  biliary  ducts.  It  begins  round  the  intralobular  branches  of 
the  ducts,  and  envelopes  each  lobule  so  as  to  insulate  it  from  its  neighbovu-. 
It  forms  a  less  regular  meshwork  than  the  preceding  variety,  and  is  a  more 
difiused  growth,  which  in  some  parts  is  thick  and  dense  so  as  completely  to 
destroy  the  hepatic  tissue ;  in  others,  is  comparatively  scanty  and  ill-de- 
veloped. The  afiected  ducts  become  largely  dilated  and  their  epithelium  is 
increased.  New  ducts  are  also  developed,  and  can  be  seen  by  the  micro- 
scope embedded  in  the  new  fibroid  tissue.  In  this  form  of  the  disease,  the 
obstruction  is  chiefly  in  the  ducts,  so  that  there  is  no  necessary  interference 
with  the  portal  circulation. 

These  two  forms  of  the  disease,  from  their  anatomical  origin,  have  been 
called  portal  and  bihary  cirrhosis. 

There  is  a  third  form  which  is  very  rarely  met  with.  It  has  only  been 
noticed  in  some  cases  of  inherited  syphihs  in  the  infant.  The  disease  is 
here  primarily  intralobular,  and  developes  within  the  lobules  round  the 
individual  Uver-cells.  This  form,  as  it  is  only  discovered  after  the  death  of 
the  child,  and  probably  gives  rise  to  no  symptoms,  need  not  be  further  re- 
ferred to. 

Syni2Dtoms. — On  account  of  the  different  pathological  conditions  in  the 
atrophic  and  hypertrophic  varieties  of  hepatic  cirrhosis,  the  symptoms  in 
the  two  forms  are  not  precisely  similar.  In.  both  we  find  signs  of  interfer- 
ence with  general  nutrition,  but  as  the  morbid  change  affects  chiefly  the  por- 
tal circulation  in  the  one  variety,  and  the  biliary  conduits  in  the  other,  the 
later  phenomena  differ  greatly  in  the  two  cases,  and  are  usually  character- 
istic. 

In  atrophic  cirrhosis,  the  early  symptoms  are  merely  those  of  indiges- 
tion, flatulence,  and  general  discomfort.  The  child  is  of  ten  peevish  and  fret- 
ful ;  he  is  restless,  sleeping  badly  at  night ;  and  his  complexion  is  sallow  or 
pasty-looking,  with  dark  discolouration  of  the  lower  eyelids.  He  is  noticed 
early  to  be  flabby,  and  sometimes  is  evidently  losing  flesh.  His  bowels  are 
often  costive.  These  symptoms  may  continue  for  a  long  time  without 
change.  The  urine  is  apt  to  be  thick  with  lithates,  and  may  contain  crys- 
tals of  uric  acid,  or  even  a  deposit  of  uric  acid  sand.     It  is  often  very  acid. 

Sooner  or  later,  more  distinctive  symptoms  begin  to  be  noticed,  and  in 
hospital  patients  it  may  be  only  from  this  point  that  the  child's  illness  is 


728  DISEASE   EN"   CHILDEEN. 

dated  by  the  parent.  The  occurrence  of  ascites,  with  swelling  of  the  belly, 
is  usually  the  first  symptom  complained  of,  and  there  may  be  some  wander- 
ing pains  in  the  side.  When  the  child  comes  under  observation,  we  usually 
find  dilatation  of  the  superficial  abdominal  veins,  distinct  fluctuation  in  the 
abdomen,  and  often  a  slight  enlargement  of  the  liver  and  spleen.  There  is 
little  or  no  jaundice,  but  the  skin  after  a  time  begins  to  have  an  earthy  tint, 
and  feels  dry  and  rough  to  the  finger.  Sometimes  there  is  a  little  oedema 
of  the  feet.  The  ascites  is  found  to  vary  greatly  in  amount,  and  the  general 
condition  of  the  child  is  subject  to  rapid  variation.  On  some  days  he  seems 
much  better  than  on  others,  and  may  be  then  lively,  playful,  and  although 
easily  tu-ed,  even  active  if  allowed  to  be  on  his  feet.  As  the  disease  pro- 
gTesses,  the  liver  shrinks  and  ceases  to  be  felt,  but  the  spleen  in  most  cases 
continues  to  increase  in  size.  If  the  ascites  is  great,  it  is  often  difficult  to 
feel  the  spleen  even  when  the  child  is  laid  on  his  right  side.  In  such  cases, 
it  may  be  often  readily  detected  by  placing  the  patient  on  his  hands  and 
knees.  The  weight  of  the  organ  then  brings  it  well  forward  within  the 
reach  of  the  fingers.  Haemorrhages  occur  in  the  child  from  the  gastro- 
intestinal mucous  membrane  as  they  do  in  the  adult ;  and  the  motions  may 
be  dark  and  sooty  from  blood,  or  pure  blood  may  be  passed  by  stool.  Vomit- 
ing of  blood  is  also  sometimes  met  with.  In  many  cases,  we  find  a  tendency 
to  haemorrhage  from  other  parts.  The  nose  and  gums  may  bleed,  and 
ecchymotic  spots  may  be  noticed  on  the  skin.  As  the  symptoms  increase, 
the  digestive  derangements  become  more  and  more  disturbed.  The  child 
is  much  troubled  with  weight  in  the  epigastrium,  and  abdominal  pains. 
He  often  feels  sick ;  sometimes  he  vomits ;  his  tongue  is  fui-red ;  he  is  thirsty, 
and  his  appetite  is  capricious  or  is  lost.  He  gets  thinner  and  thinner; 
the  dingy  hue  of  his  skin  becomes  more  and  more  marked ;  even  at  this 
early  age,  haemorrhoidal  swellings  may  be  noticed,  and  the  distention  of  the 
superficial  abdominal  veins  is  increased. 

"When  the  disease  reaches  this  period,  life  is  very  near  its  close.  Often 
there  is  general  dropsy,  but  the  child  may  sink  and  die  without  the  ap- 
pearance of  any  fresh  symptoms  ;  or  diarrhoea  may  come  on  and  prove  rapidly 
fatal.  In  other  cases  he  dies  from  haemorrhage,  or  from  an  intercurrent 
inflammation,  such  as  pleurisy  or  pneumonia.  Unless  a  complication  be 
present,  there  is  never  any  fever.  The  progress  of  atrophic  cirrhosis  is 
slow,  especially  in  the  earlier  stages.  If  haemorrhage  occurs,  it  is  usually  a 
sign  that  the  illness  is  a^Dproaching  its  termination. 

In  the  hypertrophic  variety  of  cirrhosis,  the  initial  symptoms  of  gastro- 
intestinal derangement,  pallor,  and  wasting,  are  the  same  as  in  the  other 
form  ;  but  the  after-course  of  the  disease  varies  from  the  previous  type. 
While  in  atrophic  cirrhosis  the  more  characteristic  phenomena  are  de- 
pendent upon  the  obstruction  to  the  portal  circulation,  in  the  hypertrophic 
variety  the  symptoms  are  due  to  interference  with  the  biliary  system  of 
ducts.  Jaundice,  rare  and  faint  if  it  occur  at  aU  in  the  previous  form,  is 
here  an  early  and  characteristic  symptom.  The  skin,  conjunctivae,  and 
urine  soon  become  deeply  tinged  with  orange  yellow,  and  the  motions  are 
light-coloured  or  chalky.  The  liver  is  generally  enlarged,  and  the  spleen 
in  most  cases  can  be  felt  of  unusual  size  ;  but  there  is  little  dilatation  of  the 
superficial  veins  of  the  abdomen.  Pain  may  be  complained  of  over  the 
liver.  The  bowels  are  relaxed  or  inclined  to  be  costive.  There  is  no  as- 
cites. 

As  the  disease  progresses,  the  jaundice  increases  in  intensity,  and.  the 
symptoms  generally  undergo  temporary  exacerbation.  At  these  times,  rapid 
enlargement  of  the  liver  is  noticed  ;  there  is  slight  fever  ;  the  child  is  peevish 


CIRRHOSIS   OF   THE   LIVER — SYMPTOMS — DIAGNOSIS.  729 

and  fretful,  crying  with  pain  in  his  side,  and  his  condition  appears  to  be 
changing  quickly  for  the  worse. 

The  iUness  often  closes  with  all  the  signs  of  malignant  jaundice,  due, 
probably,  to  acute  degeneration  of  the  hepatic  cells.  The  pulse  undergoes 
curious  alterations  in  frequency,  sometimes  beating  rapidly,  at  others 
slackening  to  60  or  70.  The  tongue  gets  dry  and  brown,  and  sordes 
appear  on  the  teeth.  The  child  refuses  food,  and  seems  to  care  only  to  be 
left  alone.  He  sleeps  much,  and  is  drowsy  and  stupid  when  awake. 
Petechise  are  often  seen  on  the  skin  ;  the  gums  may  bleed,  and  blood  may 
be  vomited  from  the  stomach.  The  drowsiness  soon  deepens  into  stupor  ; 
and  the  child  lies  with  his  eyes  closed,  insensible  to  aU  that  passes,  often 
grinding  his  teeth  continuously.  There  is  no  jjyrexia.  The  wasting  is 
now  rapid,  and  the  patient  sinks  and  dies  without  recovering  conscious- 
ness.    Sometimes  death  is  preceded  by  convulsions. 

Although  these  two  types  of  the  disease  differ  in  the  distribution  of 
the  fibroid  overgrowth  in  the  liver,  they  may  be  both  present  together. 
In  such  cases  the  liver  is  enlarged,  and  we  find  jaundice  combined  with 
ascites  and  swelling  of  the  abdominal  veins.  The  hepatic  disease  may  be 
the  only  lesion  of  the  kind  present,  or  may  be  accompanied  by  similar 
changes  in  the  lungs,  the  kidneys,  or  the  spleen. 

Diagnosis. — So  many  cases  are  now  on  record  of  hepatic  cirrhosis  oc- 
curring in  children  that  the  diagnosis  should  be  no  more  difficult  in  them 
than  it  is  in  the  adult.  It  is  probable  that  many  cases  of  ascites,  the  origin 
of  which  is  obscure,  may  be  attributed  correctly  to  this  condition  of  the 
liver.  If  in  such  a  case  fibroid  disease  of  the  lungs  can  be  detected,  it  ren- 
ders a  similar  condition  of  the  liver  highly  probable.  A  swollen  fluc- 
tuating abdomen,  an  enlarged  spleen,  dilatation  of  the  superficial  veins  of 
the  belly,  piles,  a  dry,  faded,  earthy  skin — these  symptoms  occurring  in  a 
child  who  is  not  feverish,  but  who  has  a  history  of  previous  failure  of 
health  and  of  wasting,  should  make  us  strongly  suspect  the  existence  of 
the  atrophic  form  of  cirrhosis.  The  absence  of  fever  is  an  imj)ortant  ele- 
ment in  this  group  of  symptoms.  If  haemorrhages  occur  from  the  stomach 
and  bowels,  or  elsewhere,  the  temperature  still  remaining  normal,  the 
symptom  is  strongly  confirmatory  of  our  opinion.  The  chief  difl&culty  in 
these  cases  arises  from  the  occurrence  of  a  febrile  complication  ;  but  this 
is  a  source  of  perplexity  common  to  most  forms  of  chronic  disease  in  the 
child.  If  there  be  fever  when  the  child  first  comes  under  observation,  it 
is  advisable  to  withhold  a  positive  opinion  until  time  has  been  allowed  for 
the  pyrexia  to  subside. 

In  the  case  of  hyj)ertrophic  cirrhosis,  the  occurrence  of  gradually  in- 
creasing jaundice,  with  an  enlarged  liver  and  pains  in  the  side,  but  without 
ascites,  piles,  or  dilated  parietal  veins  of  the  belly,  the  child  being  the 
subject  of  chronic  digestive  derangement  and  wasting,  is  a  characteristic 
grouping  of  symptoms.  If  the  illness  end  with  convulsions,  coma,  a  ty- 
phoid condition,  and  the  symptoms  of  malignant  jaundice,  the  case  may  be 
mistaken  for  one  of  acute  yellow  atrophy,  especially  if,  as  may  happen, 
the  liver  is  not  notably  enlarged.  The  latter  is,  however,  an  acute  disease, 
and  comes  on  very  abruptly,  with  few  or  no  premonitory  symptoms  ;  while 
hypertrophic  cirrhosis  is  essentially  a  chronic  illness,  with  a  long  history 
of  failing  health.  Moreover,  acute  yellow  atrophy  is  so  rare  in  the  child 
that  it  may  be  practically  excluded  from  consideration. 

Prognosis. — When  the  disease  reaches  the  stage  at  which  signs  of 
serious  impairment  of  nutrition  are  noticed,  evidenced  principally  by  a 
dry,  earthy-looking    skin,  the    prognosis  is   very   unfavourable ;    and  if 


730  DISEASE   IN   CHILDEEIf. 

hsemorrliages  occur,  the  end  may  be  judged  to  be  near.  At  an  earlier 
period,  wben  the  spirits  are  fairly  good,  even  although  there  be  consider- 
able ascites,  we  may  take  a  less  gloomy  view  of  the  case.  The  more  se- 
rious symptoms  are  sometimes  found  to  clear  away  completely — for  a  time, 
at  any  rate,  even  if  they  subsequently  return. 

In  the  case  of  hypertrophic  cirrhosis,  rapid  alternations  in  the  rapidity 
of  the  pidse,  or  drowsiness  and  nervous  symptoms,  are  of  very  unfavour- 
able import. 

Treatment. — It  is  so  seldom  jpossible  in  the  child  to  ascertain  the  exist- 
ence of  hepatic  cirrhosis  in  the  earlier  stage,  that  treatment  at  this  period 
is  confined  to  attention  to  the  digestion,  and  to  the  ef&cient  performance 
of  the  various  organic  functions.  When  the  more  characteristic  symp- 
toms begin  to  be  noticed,  there  are  two  foi-ms  of  treatment  which  may  be 
adopted.  The  patient  may  be  treated  with  alkahes  and  aperients,  or  with 
tonics.  On  account  of  the  gastric  derangement,  an  alkah  with  a  vegetable 
bitter  is  usually  prescribed,  and  this  mode  of  treatment  answers  veiy  weU 
in  most  cases.  For  a  child  of  ten  years  old  we  may  give  eight  or  ten 
grains  of  bicarbonate  of  soda  with  infusion  of  chii'etta  or  calumba  ;  and 
the  addition  of  a  few  drops  of  the  tincture  of  nux  vomica  increases  the 
efficacy  of  the  mixture.  Most  cases,  however,  do  better  under  the  use  of 
iron  and  quinine.  Ten  or  fifteen  drops  of  the  tinctui'e  of  perchloride  of 
iron  with  a  grain  of  quinine  given  three  times  a  day,  and  continued  for  a 
lengthened  period,  often  seem  to  have  great  value  in  reducing  the  ascites 
and  improving  the  general  condition  of  the  child.  Mild  aperients  should 
also  be  made  use  of,  and  laxative  doses  of  the  Carlsbad  or  Hunyadi  Janos 
waters  are  weU  borne  in  these  cases.  A  good  form  of  iron  is  the  exsiccated 
sulphate,  which  agrees  well  with  children.  It  must,  however,  be  given  in 
full  doses  ;  and  two  to  five  grains,  according  to  the  age  of  the  child,  may 
be  taken  after  each  meal  in  a  teaspoonful  of  glycerine.  The  diet  should 
be  liberal.  It  is  well  to  aUow  meat  twice  a  day  ;  and  farinaceous  foods 
may  be  used,  having  due  regard  to  the  state  of  the  stomach  and  the 
child's  power  of  digesting  them.  The  action  of  the  skin  should  be  pro- 
moted by  a  daily  warm  bath,  a«id  the  patient  should  be  dressed  from  head 
to  foot  in  flannel  or  some  warm  woollen  material. 

The  ascites  is  not  benefited  by  the  ordinary  dim'etics,  but  Dr.  Basham's 
chalybeate  diuretic,  in  which  the  iron  is  kept  in  solution  by  the  acetic 
acid,'  I  have  sometimes  thought  to  be  useful. 

If  much  fluid  accumulates  in  the  peritoneal  cavity,  and  causes  distress 
by  interfering  with  the  action  of  the  diaphragm,  the  efi^lsion  must  be  re- 
moved by  tapping  the  abdomen.  The  operation  is  accompanied  by  no 
danger  to  the  child,  if  the  aspirator  or  a  flne  trocar  be  used.  It  should  be 
performed  early  and  repeated  as  often  as  is  necessary.  Hemorrhages, 
unless  they  are  copious,  need  not  modify  the  treatment,  but  sufficient 
bleeding  to  manifestly  weaken  the  patient  must  be  combated  with  gaUic 
acid,  dilute  sulphuric  acid,  and  other  styptics.  Severe  dyspeptic  symptoms 
are  best  treated  with  bismuth  and  alkahes. 


3  •  Tinct.  f erri  perchloridi Tl^  x. 

Acidi  acetici  diluti Tfl^  x. 

Liq.  ammoniEe  acetatis 3  ss. 

Aquam ^^-  Z  ^s. 

M.  ft.  liaustus.     Siff.  To  he  taken  three  times  in  tlie  day. 


CHAPTER  TV. 

AMYLOID   LIVER. 

Amxloid,  albuminoid,  or  lardaceous  degeneration  is  a  common  lesion  in 
the  child,  and  the  liver  is  often  found  to  be  enlarged  from  this  cause.  The 
liver,  however,  may  not  suffer  alone.  The  spleen  commonly,  and  the  kidney 
frequently,  are  also  affected ;  and  often  there  is  a  similar  condition  of  the 
lymphatic  glands. 

Causation. — The  degeneration  is  always  secondary  to  a  general  cachectic 
condition.  It  occurs  sometimes  in  syphilitic  children,  and  may  be  a  conse- 
quence of  scrofula  and  tubercle.  The  commonest  cause  is,  however,  the 
existence  of  chronic  suppurations  and  purulent  discharges.  In  fibroid  in- 
duration of  the  lung,  where  there  is  a  copious  secretion  in  the  dilated  bron- 
chi, amyloid  disease  is  a  familiar  symptom  ;  and  in  cases  of  empyema  in 
early  life,  if  a  chronic  fisttdous  opening  become  established,  lardaceous  de- 
generation of  organs  very  generally  follows. 

Morbid  Anatomy. — The  amyloid  liver  is  uniformly  enlarged,  heavy,  and 
excessively  dense.  Its  edge  is  thin  and  resisting ;  its  peritoneal  coat  very 
smooth  and  tense.  The  section  is  dry  and  homogeneous  looking,  of  a  gray 
colour  and  a  gUstening  bacony  appearance.  No  blood  oozes  from  the  cut 
surface.  If,  as  sometimes  happens,  there  is  concurrent  fatty  degeneration, 
the  knife  after  the  section  may  look  greasy.  The  seat  of  the  disease  in  the 
liver  has  been  disputed.  According  to  Meckel  and  Yirchow  it  aft'ects  the 
liver-cells,  while  Wagner  and  others  are  of  opinion  that  the  amyloid  change 
is  confined  to  the  capillaries,  and  that  the  cells  are  merely  atrophied.  Ac- 
cording to  Eindfleisch,  the  morbid  process  begins  in  the  arterial  zone  of  the 
hepatic  lobules,  half  way  between  the  centre  of  the  lobide  and  the  circum- 
ference, and  implicates  the  arteries,  the  capillaries,  and  the  hepatic  cells.  It 
then  spreads  to  the  centre  and  afterwards  to  the  cu-cumference  of  the  lobules. 
Kyber,  too,  declares  that  he  has  recognised  the  change  in  unmistakable  liver- 
ceUs  which  he  had  isolated  by  pencilling.  According  to  this  pathologist, 
the  trunk  and  larger  branches  of  the  hepatic  artery  are  never  affected,  the 
morbid  process  being  confined  to  the  smaller"  hepatic  arteries;  but  the 
change  may  be  detected  in  the  hepatic  and  portal  veins,  and  even  in  the  vena 
cava.  The  affected  arteries  and  capillaries  are  diseased  in  various  degrees. 
"When  the  amyloid  process  is  advanced  in  a  vessel,  its  coats  become  thickened 
and  pellucid  ;  and  the  affected  hepatic  cells  lose  their  normal  shape,  their 
granules,  bile-pigment,  and  nuclei,  and  become  irregular  and  glassy  looking. 
The  addition  of  iodine  solution  stains  the  affected  parts  of  a  I'eddish  brown 
colour,  and  sulphuric  acid  turns  them  first  violet  and  afterwards  blue. 

Symptoms. — Although  the  enlargement  is  perfectly  painless,  the  organ 
may  produce  inconvenience  by  its  weight.  It  causes  distention  of  the  belly ; 
but  as  there  is  no  compression  of  the  bile-ducts  or  of  the  branches  of  the 
portal  vein,  there  is  no  necessary  jaundice,  ascites,  or  prominence  of  the 
superficial  abdominal  veins.     All  these  symptoms  may,  however,  be  found. 


732  DISEASE   IN"   CHILDREN. 

The  mesenteric  glands,  like  other  intex-nal  organs,  frequently  participate  in 
the  amyloid  degeneration ;  and  if  the  glands  occupying  the  hepatic  notch 
are  enlarged,  they  may  compress  both  the  bile-ducts  and  the  blood-vessels 
at  this  spot.  In  such  a  case,  the  skin,  conjunctiva-,  and  urine  are  jaundiced ; 
there  is  some  effusion  into  the  peritoneum,  and  the  veins  of  the  abdominal 
parietes  are  dilated.  Even  in  the  absence  of  jaundice,  the  stools  may  be 
light-coloured  if  the  disease  is  advanced,  owing  to  impaired  function  of  the 
hepatic  cells. 

On  palpation  of  the  belly,  the  liver  is  found  to  project  several  fingers' 
breadths  below  the  margin  of  the  ribs.  Often  its  lower  edge  is  on  a  level 
■with  the  navel ;  sometimes  it  reaches  to  the  crest  of  the  ihum.  Its  sub- 
stance feels  firm  and  resisting,  and  its  edge  remains  thin  and  sharp.  There 
is  no  tenderness  on  pressure.  In  at  least  half  the  cases,  the  spleen,  too,  is 
enlarged,  and  can  be  felt  several  fingers'  breadths  below  the  ribs  on  the  left 
side. 

Digestive  disturbances  may  be  noticed.  There  may  be  loss  of  appetite 
and  vomiting ;  and  sometimes  an  obstinate  watery  diarrhoea  comes  on,  due 
to  amyloid  degeneration  of  the  intestine,  or  to  tuberculous  or  scrofulous  ul- 
ceration. The  child  is  visually  languid  and  easily  tired.  After  exertion  he 
is  apt  to  look  weary  and  haggard  ;  but  if  kept  quiet,  his  face,  although  jDaUid, 
shows  no  signs  of  distress.     Often  his  fingers  and  toes  are  clubbed. 

A  constant  symptom  of  amyloid  disease  is  ansemia,  and  the  poorness  of 
blood  is  marked  in  proportion  to  the  intensity  of  the  degeneration.  Con- 
sequently, in  severe  cases,  the  skin  and  mucous  membranes  are  pallid,  and 
some  oedema  of  the  legs  and  feet  may  be  noticed.  Still,  no  doubt,  the  kid- 
neys in  many  cases  participate  in  the  amyloid  disease,  and  the  anaemia  and 
dropsy  may  be  partially  dependent  upon  the  renal  mischief.  Albuminuria 
and  casts  may  then  be  seen  in  the  urine,  but,  as  is  elsewhere  explained, 
these  are  not  necessary  symptoms  of  albuminoid  kidney. 

Diagnosis. — Mere  enlargement  of  the  liver  is  at  once  detected  by  palpa- 
tion of  the  belly.  It  must  be  remembered  that  a  hejDatic  swelling  often 
presses  up  the  diaphragm  on  the  right  side,  and  may  cause  dulness  and 
weak  breathing  at  the  base  of  the  right  pulmonary  region.  Such  signs 
(dulness  and  weak  breathing)  may  be  mistaken  for  signs  of  a  pleuritic  ef- 
fusion, more  particularly  as  the  signs  are  detected  all  round  that  side  of  the 
chest — in  front  as  well  as  behind.  A  distinction  may  be  made  by  noticing 
that  in  the  case  of  an  enlarged  liver  the  dulness  reaches  up  to  a  higher  level 
in  front  than  it  does  at  the  back  (in  j)leurisy  it  is  higher  behind) ;  that  the 
dulness  does  not  pass  abruptly  into  resonance,  as  it  would  do  in  the  case  of 
fluid,  for  the  thin  border  of  the  lung  overlies  the  upper  margin  of  the  liver 
and  produces  a  modified  tubular  or  tympanitic  note  at  that  point ;  and, 
lastly,  that  there  is  no  alteration  of  the  percussion-note  in  the  dull  area 
when  the  patient  lies  on  his  left  side.  A  dull  note  replaced  by  resonance 
on  change  of  position  is  characteristic  of  fluid ;  and  if  the  quantity  of  fluid 
be  small,  with  little  thickening  of  the  pleura,  this  test  of  the  effect  of  gravity 
upon  the  percussion-note  will  usually  give  satisfactory  results  in  the  child. 

A  liver  enlarged  from  amyloid  degeneration  is  smooth  and  particularly 
firm  and  resisting.  It  often  feels  hard  Hke  wood.  Its  edge  is  thin  and  not 
rounded,  and  pressure  upon  it  produces  no  uneasiness.  Such  a  liver,  un- 
accompanied by  jaundice  or  ascites,  and  found  in  a  cachectic,  pallid  child 
who  has  a  syphilitic  history,  or  has  been  the  subject  of  bone  disease  or  other 
form  of  prolonged  suppuration,  is  in  all  probabihty  albuminoid.  If  the 
spleen  is  also  enlarged,  and  there  is  albuminuria  with  hyaline  casts,  there 
can  be  little  doubt  of  the  correctness  of  this  opinion.     Absence  of  splenic 


AMYLOID   LIVEE — PEOGNOSIS — TREATMENT.  733 

dulness  does  not  exclude  albuminoid  disease,  for  an  amyloid  spleen  is  not 
always  bigger  than  natural.  In  half  the  eases  the  size  of  the  spleen  is  not 
increased. 

Hepatic  enlargement  from  congestion  rarely  occui-s  in  cachectic,  anse- 
mic  children  ;  and  a  fatty  liver  is  soft  and  yielding  instead  of  hard  and 
resisting  ;  moreovei',  it  is  not  accompanied  by  enlargement  of  the  spleen 
or  albuminuria. 

Prognosis. — The  presence  of  amyloid  degeneration  of  the  liver  in  any 
cachectic  child  must  necessarily  be  considered  as  an  additional  element  of 
danger.  There  is,  however,  reason  to  believe  that  this  form  of  disease  is 
of  less  serious  augury  in  the  young  subject  than  it  is  in  the  adult,  pro- 
vided that  the  source  of  irritation  and  suppuration  can  be  removed.  It 
is  undeniable  that  in  cases  in  which  enlargement  of  the  liver  and 
spleen  exactly  resembling  amyloid  disease  complicates  old-standing  ne- 
crosis of  bone  in  scrofulous  children,  removal  of  the  bone  disease  by  a 
suitable  operation  is  often  followed  by  a  return  of  the  liver  and  spleen  to 
their  normal  dimensions,  and,  to  all  appearance,  by  complete  recovery  of 
health.  Mr.  Barwell  has  recorded  some  remarkable  cases  of  this  kind. 
In  one  of  these  the  urine  was  also  albuminous  and  contained  casts  of  tubes ; 
but  after  the  operation  the  urine  gradually  became  normal,  and  the  dis- 
eased organs  eventually  returned  to  their  normal  size.  It  may  be  objected 
that  in  such  cases  the  enlargement  is  not  due  to  amyloid  disease.  That 
it  is  so  cannot  of  course  be  proved,  as  the  crucial  test  of  dissection  is 
wanting.  It  can  only  be  said  that  the  organs  diseased  are  those  com- 
monly diseased  in  albuminoid  degeneration  ;  that  the  symptoms  and 
physical  signs  are  such  as  are  found  in  cases  of  this  form  of  illness  ;  and 
that  the  causes  which  are  acknowledged  to  be  powerful  in  producing  al- 
buminoid lesions  have  been  in  operation. 

Treatment. — The  treatment  of  amyloid  degeneration  consists,  in  the 
first  place,  in  attending  to  the  cause  of  the  disease,  and  removing  any  long- 
standing suppurations  and  exhausting  discharges  which  may  be  increasing 
the  cachexia  and  adding  to  the  weakness  of  the  patient.  If  necrosis  of 
bone  or  suppuration  of  a  joint  be  present,  the  aid  of  a  surgeon  is  required. 
Fibroid  induration  of  the  lung,  or  a  chronic  fistulous  opening  in  the  chest- 
wall,  must  be  treated  as  directed  in  the  chapters  referring  to  these  sub- 
jects. We  must  do  our  best,  in  the  next  place,  to  remove  any  secondary 
comphcations  which  may  be  helping  to  reduce  the  strength  of  the  child. 
The  bowels  must  be  attended  to  ;  diarrhoea,  if  present,  must  be  arrested, 
and  if  there  be  any  reason  to  suspect  scrofulous  or  tubercular  ulceration 
of  the  intestinal  mucous  membrane,  suitable  remedies  must  be  employed, 
as  is  elsewhere  described.  Vomiting  must  be  checked  by  bismuth,  dilute 
prussic  acid,  and  the  sucking  of  ice. 

For  the  liver  itself,  the  preparations  of  iodine  are  very  generally  rec- 
ommended ;  and  as  there  is  always  more  or  less  anaemia,  iron  may  be 
judiciously  combined  with  this  treatment.  I  prefer  giving  the  drugs 
singly,  and  have  often  prescribed  (for  a  child  of  five  years  of  age)  five  drops 
of  the  tinctare  of  iodine  to  be  given  freely  diluted  before  food,  and  five 
grains  of  the  exsiccated  sulphate  of  iron  in  glycerine  directly  after  each 
meal.  If  the  intestinal  mucous  membrane  be  healthy,  this  preparation  of 
iron  does  not  irritate,  and  given  in  sufficiently  large  doses,  is  of  great  value 
in  the  treatment  of  cachectic  conditions  in  the  child.  If  ulceration  of  the 
bowels  be  present,  it  is  less  suitable.  The  syrup  of  the  iodide  of  iron  so 
often  disagrees,  prom_oting  acidity  and  flatulence,  that  I  have  long  since 
abandoned  its  use.    Iodide  of  potassium,  combined  with  the  citrate  of  iron, 


734  DISEASE  IK   CHILDKEN. 

may  be  employed  ;  but  the  iodide  should  be  administered  in  appreciable 
doses.  It  should  be  rarely  given  in  smaller  quantities  than  one  grain  for 
each  year  of  the  child's  life.  I  cannot  remember  ever  seeing  any  uncom- 
fortable symptoms,  such  as  are  common  in  the  adult,  produced  by  this 
remedy.  Gardiner's  syrup  of  hydriodic  acid  (Til  xv.-xxx.)  is  also  applicable 
to  these  cases.  Dr.  Warburton  Begbie  speaks  highly  of  the  effects  of  mu- 
riate of  ammonia  in  the  adult.  It  may  be  given  to  the  chUd  in  ten-grain 
doses  freely  diluted. 

The  dropsy,  being  the  consequence  of  the  ansemia,  must  be  treated 
with  iron  ;  and  the  chalybeate  diuretic  of  Dr.  Basham,  recommended  else- 
where, '  is  here  also  of  service.  If  the  bowels  are  healthy,  an  occasional  dose 
of  the  compound  jalap  powder  will  further  the  removal  of  the  subcutan- 
eous effusions. 

The  chUd  must  be  put  on  a  liberal  diet  suited  to  his  age  and  powers  of 
digestion  ;  and  if  the  kidneys  are  not  implicated,  he  wiU  be  benefited  by 
stimulants.  The  St.  Kaphael  tonic  vdne  is  useful  in  these  cases.  A  suit- 
able climate  adds  greatly  to  the  patient's  chances  of  recovery.  Dr.  Begbie 
recommends  a  lengthened  sea  voyage  ;  and  there  is  no  doubt  that  condi- 
tions under  which  the  child,  warmly  clothed,  can  pass  the  chief  hours  of 
the  day  in  a  fresh,  bracing  air,  are  the  most  favoiirable  to  permanent  im- 
provement. German  writers  speak  highly  of  the  sulphurous  springs  of 
Aix-la-Chapelle,  and  the  waters  of  Ems  and  Weilbach,  iii  their  influence 
upon  this  form  of  hepatic  enlargement. 

1  See  page  730. 


CHAFTEE  Y. 

FATTY   LIVER. 

Fatty  liver  may  be  of  two  kinds.  The  one  consists  in  a  mere  abnormal 
deposition  of  fat-giobules  in  the  hepatic  cells  without  any  injury  or  degen- 
eration of  the  cell- wall.  This  is  called  fatty  infiltration.  The  other  is  fatty 
degeneration,  in  which  the  nutrition  of  the  liver-cells  is  interfered  with. 
They  undergo  a  retrograde  metamorphosis,  and  fat  granules  appear  in  them. 
Each  of  these  varieties  may  be  found  in  the  child.  They  are  most  common 
in  infancy  and  the  earlier  period  of  childhood. 

Causation. — Fatty  infiltration  of  the  liver  may  arise  in  the  child  from 
two  causes : — From  overfeeding  with  farinaceous  foods,  and  from  various 
forms  of  exhausting  disease.  In  the  first  case,  the  hydrocarbon  is  supplied 
from  without,  and  being  in  excess,  is  deposited  in  the  liver  in  the  form  of 
fat.  Deposition  of  fat  under  such  circumstances  may  be  looked  upon  rather 
as  a  physiological  than  a  pathological  j)rocess.  It  is  often  a  merely  tem- 
porary phenomenon,  and  ceases  when  the  diet  is  changed.  In  the  case  of 
exhausting  disease,  such  as  tubercle,  scrofula,  intestinal  catarrh,  syphilis, 
rickets,  etc. ,  the  fat  is  reabsorbed  from  the  subcutaneous  and  other  fatty 
tissues.  According  to  Oppenheimer,  in  infants  dying  during  the  second  or 
third  week  of  entero-colitis,  the  liver,  although  of  normal  appearance  to  the 
naked  eye,  is  the  seat  of  a  real  fatty  degeneration.  Fatty  granules  are  seen 
in  the  hepatic  ceUs  along  the  whole  course  of  the  portal  vessels,  and  the  de- 
generation is  preceded  by  the  formation  of  an  abnormal  plasma  in  the  cells 
which  completely  obscures  the  nuclei.  In  other  structural  diseases  of  the 
liver,  fatty  degeneration  may  occur  as  a  secondary  lesion. 

Morbid  Anatomy. — The  size  of  the  liver  is  not  altered  unless  the  fatty 
change  is  carried  to  a  high  degree.  In  that  case  all  its  measurements  are 
increased  and  its  edge  is  blunted.  The  surface  is  lighter  coloured  than 
natural,  and  may  have  an  oily,  shining  appearance.  The  hepatic  substance 
feels  soft  and  doughy  to  the  touch,  and  the  section  is  yellowish  red  or 
yellow.  In  extreme  cases  the  blade  of  the  knife  looks  greasy  after  the  sec- 
tion. By  the  microscope  granules  and  globules  of  fat  are  seen  in  the  he- 
patic cells.  The  oily  drops  are  larger  in  proportion  to  the  stage  to  which 
the  infiltration  has  advanced  ;  and  if  the  process  be  carried  to  a  high  de- 
gree, the  cells  may  each  be  filled  by  one  large  drop  of  oil.  The  ceUs  at  the 
circumference  of  the  lobides  near  to  the  intra-lobular  veins  are  first  and 
principally  affected.  Those  towards  the  centre  are  much  more  healthy. 
Therefore,  on  closely  inspecting  a  lobule,  the  part  immediately  surrounding 
the  central  vein  will  be  found  much  redder  in  colour  than  the  periphery. 
The  fat  consists  of  olein  and  margarine,  with  traces  of  cholesterine. 

Symptoms. — If  the  organ  is  not  enlarged,  and  the  degree  of  fatty  infil- 
tration is  slight,  symptoms  may  be  absent  altogether.  Even  if  the  liver  is 
enlarged,  there  is  little  to  draw  attention  to  the  belly.  Some  tenderness 
may  be  noticed  in  the  right  hypochondrium  when  this  is  pressed,  and  in 


736  DISEASE  IIST   CHILDRET^. 

exceptional  cases  the  child  may  complain  of  a  feeling  of  heaviness  on  that 
side.  Cases  where  the  size  of  the  Hver  is  notably  increased  from  this  cause 
are  usually  those  of  phthisical  children.  There  may  be  some  digestive  de- 
rangement from  interference  with  the  portal  circulation,  but  there  is  never 
jaundice  or  ascites.  The  fatty  hver  is  not  always  easy  to  feel,  as  it  yields 
readily  under  the  linger,  and  is  easily  depressed  from  the  surface.  Conse- 
quently, like  the  softened  spleen  in  typhoid  fever,  its  edge  may  elude  the 
touch.  It  is  of  the  utmost  importance,  in  consideration  of  cases  such  as 
these,  to  lose  no  opportunity  of  practising  the  sense  of  touch  and  accustom- 
ing the  finger  to  appreciate  slight  differences  in  resistance. 

In  fatty  degeneration  ^of  the  Hver,  there  is  no  increase  in  size  of  the  or- 
gan, and  the  disease,  occui-ring  as  it  does  in  the  course  of  some  exhausting 
illness,  gives  rise  to  no  symptoms  which  can  reveal  its  jDresence.  It  is  there- 
fore seldom  discovered  during  hfe. 

Diagnosis.- — A  liver  enlarged  fi'om  fatty  infiltration  differs  from  other 
forms  of  enlarged  hver.  Instead  of  being  firm  and  resisting,  its  substance  is 
soft  and  yielding  ;  and  the  edge,  instead  of  being  sharp  and  thin,  is  rounded 
and  blunt.  Such  a  Hver  found  in  a  case  of  tubercular  or  scrofulous  j^hthisis, 
or  in  the  coui'se  of  some  other  exhausting  disease,  unaccompanied  by  jaun- 
dice, ascites,  or  dilatation  of  the  superficial  veins  of  the  abdomen,  is  in  all 
jDrobabiHty  fatty.  Thus,  in  a  Httle  gii-1,  aged  thi-ee  years,  the  subject  of  a 
chronic  hydrocephalus,  who  died  in  the  East  London  Children's  Hospital 
from  acute  tuberculosis,  the  Hver  on  the  child's  admission  was  found  to 
reach  as  far  downwards  as  the  level  of  the  umbiHcus.  Its  edges  were 
rounded  and  its  substance  seemed  to  be  normal.  There  was  no  sign  of 
jaundice ;  the  supei-ficial  veins  of  the  belly  were  not  visible,  nor  could  any 
fluctuation  be  detected  in  the  abdomen.  The  spleen  was  also  enlarged. 
After  death,  the  Hver  was  fouud  to  be  greatly  increased  in  size.  Its  con- 
sistence was  softer  than  natural,  its  colour  a  fawn  brown,  and  some  yeUow 
miliary  nodules  were  seen  on  the  surface.  Its  section  had  a  gi'easy  look. 
The  spleen,  which  was  also  enlarged,  was  studded  with  tubercles. 

Prognosis. — A  remarkably  fatty  Hver  occuriing  in  the  course  of  a  linger- 
ing iUness  impHes  serious  interference  with  nutrition ;  but  the  prognosis 
depends  more  upon  the  primary  disease  than  upon  the  state  of  the  Hver. 

Treatment. — The  indications  for  treatment  must  be  derived  from  the 
primary  disease  in  the  course  of  which  the  fatty  condition  of  the  organ  has 
arisen.  If  a  child  is  known  to  be  taking  extravagant  quantities  of  faidna- 
ceous  food,  measures  must  be  taken  at  once  to  put  a  stop  to  such  excess ; 
but  many  other  s;vT3iptoms  besides  fatty  liver  may  be  the  consequence  of 
such  a  dietary.     This  subject  is  treated  of  elsewhere  (see  Gastric  Catan-h). 


CHAPTER  YL 

HYDATID  OF  THE  LIVER. 

Hydatid  of  the  liver  is  sometimes  foimd  in  childhood.  The  disease  sel- 
dom occurs  earlier  than  the  fourth  year  of  life,  although  Cruveilhier  has 
quoted  a  case  in  an  infant  twelve  days  old,  and  M.  Archambault  has 
seen  it  in  a  child  aged  three  years  and  a  half.  Between  the  fourth  and 
eighth  year  it  is  sometimes  met  with,  but  is  still  rare.  After  the  eighth 
year  it  is  more  common.  The  earUest  age  at  which  the  disease  has  come 
under  my  own  notice  has  been  five  years  and  a  half. 

Causation. — The  hydatid  growth  becomes  implanted  in  the  human  liver 
as  a  result  of  the  introduction  into  the  stomach  and  intestines  of  the  ova 
of  the  tasnia  echinococcus.  This  creature  is  a  parasitic  worm  inhabiting 
the  alimentary  canal  of  the  dog  and  wolf.  The  tape-worm  is  a  quarter  of 
an  inch  in  length,  and  has  four  joints,  the  last  of  which  (the  proglottis  or 
sexually  matiure  segment)  contains  the  ova.  The  ova  are  excreted  by  the 
animal  in  whose  intestines  they  have  found  a  lodgment,  and  contaminating 
water  or  articles  of  food,  become  introduced  into  the  human  body.  It  is 
probable,  also,  that  the  ova  and  scolices  may  be  sometimes  conveyed  to  the 
child  directly.  In  the  dog,  the  presence  of  the  worm  in  the  bowels,  and 
the  passage  of  the  eggs  and  embryos  in  large  numbers  through  the  anus, 
causes  considerable  irritation,  which  the  animal  endeavours  to  relieve  by 
licking.  If  directly  afterwards  he  apply  his  tongue  to  the  face  and  mouth 
of  the  child,  the  parasite  may  pass  at  once  to  the  child's  tongue  and  be 
swallowed.  How  it  travels  from  the  aUmentary  canal  to  the  liver  is  not 
clear. 

Hydatid  disease  is  endemic  in  Iceland,  where  the  children  are  often  af- 
fected. The  enormous  number  of  dogs  maintained  on  the  island  has  been 
supposed,  with  much  probability,  to  be  the  explanation  of  the  frequency 
of  the  disease. 

Morbid  Anatomy. — Hydatid  tumours  are  more  common  in  the  liver 
than  elsewhere  in  the  body  ;  but  from  the  intestine  they  may  pass  not 
only  into  the  liver  but  also  into  the  spleen,  the  mesentery,  the  wall  of  the 
abdomen,  and  even  into  the  substance  of  the  heart  and  brain.  The  liver 
may  contain  one  sac  or  several.  The  sac  itself  consists  of  a  firm  fibrous 
capsule  in  close  adherence  to  the  liver  substance,  and  is  very  vascular. 
Inside  the  capsule  there  is  a  clear  gelatinous  bladder  (the  enveioj)e  of  the 
vesicle)  composed  of  numerous  fine  concentric  strata.  This  is  the  mother 
sac.  It  contains  numerous  large  and  small  vesicles  floating  in  a  clear  fluid, 
or  adherent  to  the  investing  envelope.  Some  of  the  larger  of  the  daughter 
vesicles  may  contain  smaller  sacs  still  of  a  third  generation.  These  are 
seldom  larger  than  the  head  of  a  medium-sized  pin.  The  mother  sac  itself 
varies  in  size  from  a  pea  to  a  marble,  an  orange,  or  a  child's  head.  The 
fluid  it  contains  is  non-albuminous  and  holds  in  solution  salts,  principally 
the  chloride  of  sodium.  On  careful  examination  of  this  fluid,  the  hooklets 
47 


738  DISEASE  IN   CHILDREN. 

of  the  embryos  (scolices)  of  the  taenia  echinococcus  may  be  often  recog- 
nised by  the  microscope. 

The  scolices  themselves  may  be  sometimes  found.  These  are  from  one- 
twentieth  to  one-sixth  of  a  line  in  length.  The  head,  which  resembles 
that  of  the  taenia,  has  four  suckers  and  a  trunk.  The  latter  is  encircled 
by  a  double  crown  of  booklets,  the  number  of  which  varies,  according  to 
Kuchenmeister,  from  twenty-eight  to  thirty,  or  from  forty-six  to  fifty-two. 
The  head  is  separated  from  the  body  by  a  groove,  and  at  its  posterior  end 
is  a  depression  into  which  a  cord  is  inserted.  This  attaches  it  to  the  inner 
wall  of  the  sac.  The  shape  varies  according  as  to  whether  the  head  is 
stretched  out  or  retracted.  On  the  body,  elongated  Hnes  are  seen  passing 
backwards  from  the  head.  These  are  intersected  by  transverse  striae. 
Besides  these  markings,  a  number  of  rounded  calcareous  corpuscles  can 
be  detected.  The  scolices  he  in  groups  on  the  inner  wall  of  the  cyst,  and 
can  be  seen  through  the  vesicular  wall  as  delicate  white  particles.  Some- 
times the  mother  sac  contains  scohces  but  no  daughter  vesicles.  Some- 
times it  contains  neither  vesicles  nor  embryos. 

The  sacs  may  be  seated  at  any  part  of  the  hver,  but  are  more  common 
in  the  right  lobe  than  in  the  left.  The  hver  is  generally  enlarged  by 
them,  and  may  appear  uniformly  swollen  if  the  sac  is  deep-seated.  It' 
superficially  placed,  the  cyst  raises  a  bump  or  tumour  at  the  correspond- 
ing part  of  the  surface.  When  it  lies  close  under  the  peritoneal  coat  of 
the  hver,  this  membrane  becomes  thickened  and  may  form  adhesions  with 
parts  around.  The  j)ressure  of  the  sac  upon  the  parenchyma  of  the  organ 
causes  destruction  and  atrophy  of  the  hepatic  tissue.  The  larger  blood- 
vessels and  bile-ducts  are  seldom  affected  ;  but  occasionally  the  ducts  may 
be  obhterated,  or  a  communication  may  be  formed  between  the  sac  and  a 
large  duct  or  blood-vessel.  In  such  cases  the  death  of  the  cyst  usually  fol- 
lows. 

After  a  time  changes  generally  take  place  in  the  mother  sac.  It  may 
ruptm^e  from  over- distention,  and  only  a  few  shreds  of  the  original  vesicle 
may  be  left  amongst  the  daughter  cysts.  Sometimes  the  sac  suppurates, 
or  is  converted  into  semi-solid  atheromatous  matter  composed  of  phosphate 
and  carbonate  of  hme,  cholesterine,  and  a  substance  resembling  albumen. 
In  other  cases  adhesions  may  be  formed  with  neighbouring  parts,  and  the 
cyst  may  burst  into  the  stomach  or  bowels,  or  through  the  diaphragm 
into  the  pleura  or  lung.  Accidental  injimes  have  caused  rupture  of  the 
cyst  and  extravasation  of  its  contents  into  the  peritoneal  cavity.  In  rare 
cases  the  hydatid  sac  has  been  known  to  open  externaUy  through  the  ab- 
dominal parietes  or  a  lower  intercostal  space.  After  escape  of  the  fluid  by 
any  of  these  means,  suppuration  of  the  cyst  may  still  take  place,  and 
pyaemia  is  one  of  the  consequences  which  may  result.  Sometimes,  al- 
though rarely,  the  increase  in  thickness  of  the  capsule,  which  may  acquire 
a  cartilaginous  consistence,  so  interferes  with  the  development  of  the 
echinococcus  that  death  ensues  and  a  spontaneous  cure  is  effected.  This, 
however,  is  not  likely  to  occur  except  in  hydatids  of  small  size  which  have 
not  been  detected  during  life. 

Symptoms. — When  the  cyst  is  small  and  is  planted  deeply  in  the  sub- 
stance of  the  liver,  it  may  give  rise  to  no  symptoms  at  all.  In  most  cases, 
however,  the  liver  becomes  enlarged,  but  not  uniformly.  A  tumour  is  felt 
at  one  part  of  the  organ  which  may  project  upwards  into  the  chest  or  down- 
wards into  the  belly.  The  swelhng  is  painless  as  a  rule,  and  may  give  rise 
to  no  uneasiness,  but  a  feehng  of  weight.  It  is  smooth,  round,  often  elas- 
tic, and  may  convey  a  distinct  sense  of  fluctuation.     Sometimes,  however, 


HYDATID   OF  THE   LIVER — SYMPTOMS.  7B9 

as  in  a  case  to  be  afterwards  narrated,  it  feels  firm  and  soKd  like  a  fibrous 
growth.  In  exceptional  cases  a  sense  of  vibration,  first  described  by  Piorry 
as  the  "  hydatid  fremitus,"  is  felt  by  sharply  percussing  the  finger  allowed 
to  rest  upon  the  tumoui".  This  vibration,  according  to  Dr.  Sadde,  denotes 
the  presence  of  daughter  vesicles.  Therefore,  if  vibration  is  absent,  we 
should  expect  to  find  few  or  no  booklets.  Occasionally,  pain  has  been  no- 
ticed from  mere  distention,  as  in  a  case  mentioned  by  Frerichs,  where  the 
pain  ceased  after  puncture  and  removal  of  a  quantity  of  watery  fluid  from 
the  cyst.  As  a  rule,  pain,  if  present,  indicates  inflammation  and  suppura- 
tion of  the  sac. 

As  the  tumour  seldom  interferes  with  the  channels  of  the  bUe-ducts  or 
portal  vessels,  jaundice  and  ascites  are  rare,  and  dyspeptic  symptoms  are 
seldom  observed.  In  ordinary  cases,  therefore,  the  nutrition  of  the  child 
is  not  interfered  with,  and  there  is  no  fever.  The  patient  is  brought  for 
advice  merely  on  account  of  the  unusual  size  and  unilateral  hardness  of  his 
belly.  In  young  subjects  the  projection,  as  a  rule,  is  readily  detected  by 
the  eye,  and  if  seated  near  the  convex  surface  of  the  right  lobe,  as  it  usu- 
ally is,  forms  a  swelling  which  protrudes  downward  fi'om  beneath  the  lower 
ribs. 

A  little  boy,  aged  five  years  and  a  half,  was  brought  to  me  at  the  hos- 
pital on  account  of  the  size  of  his  belly  and  occasional  pains  which  he  com- 
jDlained  of  in  the  right  hypochondrium.  He  had,  besides,  some  cough  in 
the  morning.  On  examination  of  the  abdomen,  a  prominent  swelling  was 
discovered  in  the  hepatic  region,  bounded  above  by  the  ribs,  and  below  by 
a  line  drawn  just  below  the  level  of  the  navel.  Its  transverse  measurement 
was  three  and  a  half  inches.  The  liver  dulness  began  above  one  finger's 
breadth  below  the  nipple,  and  its  lower  edge  could  be  felt  just  below  the 
lower  border  of  the  tumour.  The  swelling  was  smooth,  elastic,  and  gave  a 
semi-fluctuating  sensation  to  the  finger.  There  was  no  hydatid  fremitus. 
When  pressure  was  made  uj)on  it,  the  child  flinched  and  said  it  was  sore. 
There  was  no  jaundice,  ascites,  or  prominence  of  the  superficial  abdominal 
veins.  The  SAvelhng  was  punctured  with  the  pneumatic  aspirator  through 
the  abdomioal  parietes,  and  about  an  ounce  of  purulent  matter  was  evac- 
uated. No  booklets  could  be  detected.  Ten  days  afterwards  the  cyst  had 
refilled.  It  was  again  punctured,  and  a  quantity  of  perfectly  clear  fluid 
escaped.  The  cyst  did  not  again  refill,  and  the  size  of  the  liver  was  greatly 
reduced  when  the  child  left  the  hospital. 

Sometimes  the  tumour,  instead  of  becoming  visible  in  the  belly,  may 
press  ujDwards  the  right  side  of  the  diaphragm  and  the  base  of  the  lung, 
and  project  far  into  the  right  side  of  the  chest.  In  such  a  case  the  lower 
ribs  on  that  side  are  pushed  outwards,  and  the  physical  signs  very  much 
resemble  those  of  a  pleuritic  effusion.  Even  if  the  tumour  project  but 
slightly  upwards,  the  resjoiratory  sounds  are  usually  very  weak  at  the  right 
posterior  base  of  the  chest,  and  the  percussion-note  may  be  a  little  higher 
pitched,  with  increased  sense  of  resistance. 

If,  instead  of  projecting  from  the  convexity  of  the  organ,  the  hydatid 
sac  protrudes  from  the  under  aspect  of  the  liver,  pressure  signs  may  be 
observed  in  connection  with  the  biliary  and  vascular  conduits.  It  is  in 
these  cases  that  jaundice,  ascites,  and  oedema  of  the  feet  may  be  noticed. 

If  spontaneous  suppuration  take  place  in  the  hydatid  sac,  the  symptoms 
vary  in  severity.  They  may  be  grave  or  trifling.  In  some  cases  a  slight 
rise  in  the  temperatiu'e  of  the  child  occurs  ;  he  looks  a  httle  poorly ; 
coughs,  and  complains  of  pain  when  his  belly  is  manijDulated,  but  nothing 
is  noticed  to  excite  the  alarm  of  the  parents.     In  other  cases  he  shivers, 


740  DISEASE  IN   CHILDKEK. 

and  Ids  temperature  undergoes  the  rapid  alternations  peculiar  to  suppura- 
tion ;  the  swelling  increases  in  size,  and,  if  left  alone,  either  points  at  some 
part  of  the  surface,  or  sets  up  adhesive  inflammation  with  a  neighbouring 
organ  and  bursts  into  it.  The  proof  that  such  an  abscess  is  the  result  of  a 
hydatid  cyst  is  the  finding  of  hydatid  membranes  or  booklets  in  the  evac- 
uated pus. 

If  the  cyst  be  not  interfered  with,  it  will  probably  in  time  destroy  the  hfe 
of  the  patient  by  bursting  into  some  neighbouring  organ.  Bohn  has  related 
the  case  of  a  child  eight  years  of  age,  in  whom  the  sac  burst  into  the  bowel. 
The  patient  recovered  ;  but  a  favovu'able  issue  to  so  severe  a  compHcatioD 
must  be  rare.  The  cyst  usually  bursts  into  the  cavity  of  the  chest — into 
the  pleura  or  the  lung.  Death  is  a  frequent  consequence  of  either  acci- 
dent. In  the  latter  case  pneumonia  is  set  up,  and  the  patient  dies  worn 
out  by  the  profuse  discharge. 

Hydatid  of  the  liver  may  be  complicated  by  a  similar  development  in 
the  spleen,  in  the  folds  of  the  mesentery,  or  beneath  the  peritoneum.  It 
is  important  to  be  aware  of  this  possible  distribution  of  the  echinococci,  as 
the  presence  of  various  tumours  in  the  abdominal  cavity  may  tend  to  em- 
barrass the  diagnosis.  Sometimes  the  lungs  as  well  as  the  hver  are  af- 
fected. These  various  cysts  often  appear  to  be  of  different  ages,  and  in 
that  case  may  arise  from  absorption  of  embryos  at  different  periods  of 
time.  It  has  been  suggested  that  germs  generated  by  the  elder  hydatids 
may  be  carried  along  by  the  current  of  blood  and  deposited  in  other 
organs  ;  but  in  this  case  they  could  hardly  be  conveyed  from  the  hver  to 
the  spleen  or  mesentery  against  the  direction  of  the  blood-current. 

Diagnosis. — The  diagnostic  features  of  a  hydatid  tumour  of  the  liver 
are  : — A  localised  swelling  of  the  organ,  smooth,  elastic,  and  painless,  ac- 
companied by  no  signs  of  jaundice,  ascites,  prominence  of  the  superficial 
abdominal  veins  or  swelling  of  the  feet,  and  giving  rise  to  no  pyrexia  or 
impairment  of  the  general  health  of  the  child.  If  the  characteristic  frem- 
itus can  be  detected  on  percussion  of  the  sweUing,  the  evidence  is  com- 
plete. 

If  suppuration  have  occurred  in  the  sac  there  may  be  some  fever,  and 
the  child  looks  ill  and  pale.  Pain  may  be  comjDlained  of  in  the  right  hypo- 
chondrium,  and  the  tumoiu-  may  be  tender  when  pressed  upon. 

If  the  tumour  feel  soHd  to  the  touch,  as  was  the  case  in  a  child  who 
was  under  my  care  in  the  hospital,  the  diagnosis  would  rest  upon  the 
slow  growth  and  painless  condition  of  the  swelling,  and  the  general 
absence  of  symptoms.  I  have  never  met  wdth  a  sarcoma  or  soft  cancer  of 
the  liver  in  a  child,  but  it  is  possible  that  this  disease  might  be  mistaken 
for  a  hydatid  cyst.  The  growth,  however,  would  be  more  rapid  in  such  a 
case,  and  we  should  expect  to  find  some  impairment  of  the  general  health. 
In  any  case  of  doubt  an  exploratory  puncture  with  a  fine  trocar  and  can- 
ula  will  remove  all  hesitation.  If  a  non-albuminous,  clear,  or  slightly 
turbid  fluid  escape,  especially  if  booklets  can  be  discovered  in  it  by  the 
microscope,  the  diagnosis  of  hydatids  is  clear. 

If  a  large  cyst  project  upwards  into  the  chest  and  compress  the  base  of 
the  lung,  it  is  often  mistaken  for  a  pleuritic  effusion.  The  error  is  one 
which  is  easily  fallen  into,  for  in  both  cases  there  is  complete  dulness,  with 
increased  sense  of  resistance  and  weak  breathing,  all  round  the  right  side 
of  the  chest.  A  distinction  may  be  made  by  observing  that  in  the  case  of 
a  hepatic  cyst  the  upper  line  of  dulness  is  ctu-ved  with  the  convexity  up- 
wardSj  and  that  the  dulness,  therefore,  reaches  higher  in  the  mid-axillary 
line  than  at  either  the  front  or  the  back  of  the  chest.     In  pleurisy  an 


HYDATID   OF   THE   LIVEE — PEOGISrOSIS — TEEATMENT.         741 

exactly  opposite  condition  is  found.  The  upper  margin  of  dulness  is  con- 
cave, being  less  elevated  in  the  infra-axillary  region  than  at  the^  back.  If 
there  is  any  suspicion  that  the  disease  is  not  pleurisy,  an  exploring  trocar, 
allowing  of  examination  of  the  fluid,  will  soon  set  the  matter  at  rest._  The 
fluid  drawn  from  the  chest  in  pleurisy  coagnalates  on  boiling,  while  the 
hydatid  fluid,  as  has  been  said,  is  non-albuminous. 

In  the  rare  cases  where  jaundice  and  ascites  are  produced  by  a  hydatid 
cyst  placed  near  the  concavity  of  the  liver,  no  locahsed  sweUing  can  be  de- 
tected, and  a  diagnosis  is  hardly  possible  unless  we  can  satisfy  ourselves 
by  puncture  or  otherwise  of  the  presence  of  a  similar  cyst  in  other  organs. 

Prognosis. — If  the  child  is  seen  before  injury  has  been  inflicted  upon 
neighbouring  organs  by  bursting  of  a  hydatid  sac  into  them,  the  prog- 
nosis is  favourable ;  for  the  slight  operative  procedure  necessary  for  the 
evacuation  of  the  fluid  and  destruction  of  the  cyst  and  its  contents  is 
usually  well  borne.  If  the  sac  has  been  evacuated  into  a  neighboming 
organ,  the  situation  is  a  very  serious  one,  and  most  of  these  cases  prove 
fatal. 

Treatment.— MiliO\\.g\i  many  internal  remedies  have  been  administered 
in  the  hope  that  the  drug  might  pass  from  the  blood  to  the  interior  of  the 
cyst,  and  so  destroy  the  life  of  the  hydatid,  it  is  now  admitted  that  such  an 
object  is  not  to  be  attained  by  physic.  Our  only  means  of  curing  the 
patient  is  to  puncture  the  cyst  and  evacuate  its  contents.  If  this  be  done 
with  a  fine  trocar  and  canula,  there  is  little  risk  of  escape  of  the  fluid  into 
the  peritoneum,  and  consequent  peritonitis.  It  is  best  to  em-ploy  the 
pneumatic  aspirator,  so  as  to  prevent  the  entrance  of  air  into  the  sac. 
After  the  withdrawal  of  its  fluid  contents,  the  hydatid  cyst  collapses  and 
its  membrane  shrinks  away  from  the  investing  capsule.  The  resulting 
space  is  rapidly  filled  by  exuded  serum,  and  the  hydatid  quickly  dies. 
Sometimes  the  operation  requires  to  be  repeated.  It  is  usually  unneces- 
sary to  employ  irritating  injections  after  emptjdng  the  sac,  but  if  the  cyst 
continually  refills,  it  may  be  desirable  to  do  so. 

A  healthy-looking,  well-nourished  girl,  aged  twelve  years,  was  under 
my  care  in  the  Victoria  Park  Hospital,  for  a  swelling  in  the  right  side  of 
the  belly  which  had  been  first  noticed  two  months  previously. 

On  examination  it  was  seen  that  the  lower  ribs  on  the  right  side  were 
distinctly  prominent,  and  that  the  intercostal  spaces  at  that  part  were  wi- 
dened. The  liver  dulness  began  at  the  lower  border  of  the  fourth  rib,  and 
the  inferior  edge  of  the  organ  could  be  felt  just  below  the  level  of  the 
umbilicus.  Immediately  below  the  ribs,  a  solid-feeling  tumour  was  dis- 
covered. This  gave  no  elastic  sensation  to  the  finger,  and  was  not  at  all 
tender  when  pressed  upon .  It  descended  somewhat  on  deep  inspii'ation. 
Below  it  the  substance  of  the  liver  could  be  felt  of  normal  density,  convey- 
ing to  the  finger  a  very  different  sensation  to  the  solid  resistance  of  the 
tumour.  Posteriorly,  the  hepatic  dulness  began  at  the  lower  angle  of  the 
scapula,  and  complete  dulness  one  interspace  lower  down.  The  respira- 
tory sounds  were  weak  at  the  right  base  behind,  and  some  friction  was 
heard  in  the  infra-axillary  region  and  at  the  base  in  front  (the  child  had 
had  pleurisy  eighteen  months  before).  There  was  no  jaundice  or  ascites, 
and  the  superficial  veins,  although  more  visible  than  natural  over  the  front 
of  the  chest,  were  not  dilated  in  the  epigastrium  or  on  the  abdominal  wall. 
The  heart's  apex  was  in  the  fifth  interspace  in  the  nipple  line.  Its  sounds 
were  healthy. 

An  exploratory  puncture  was  made  in  the  tumour  with  a  hypodermic  in- 
jection syringe,  and  some  colourless  fluid  containing  chlorides  but  no  albu- 


742  DISEASE   IN   CHILDEEjST. 

men  was  withdrawn.  No  hydatids  could  be  discovered  in  the  fluid  by  the 
microscope.  Some  days  afterwards  the  tumour  was  again  punctured  with 
the  aspirator  through  the  eighth  interspace,  and  twenty  ounces  of  a  clear, 
straw-coloui'ed  fluid  were  withdrawn,  having  the  characters  above  men- 
tioned. Its  specific  gravity  was  1.008.  No  booklets  could  be  seen  under 
the  microscope.  A  solution  of  iodine  (half  a  drachm  of  the  tinctui-e  to 
haK  an  ounce  of  water)  was  then  injected  into  the  cyst,  and  the  child  took 
a  draught  containing  five  drops  of  laudanum. 

The  operation  was  followed  by  no  rigors,  sickness,  or  other  sign  of  dis- 
comfort ;  but  the  temperature  rose  every  night  to  between  101°  and  102°, 
sinking  in  the  morning  to  nearly  the  normal  level.  A  fortnight  after  the 
first  operation,  the  tumour  being  rather  more  prominent  than  on  the 
child's  admission,  the  cyst  was  again  punctured,  and  twenty-thi-ee  ounces 
of  thick  greenish  pus  were  drawn  off.  In  another  fortnight  the  operation 
was  repeated  for  the  third  time,  removing  eleven  ounces  of  gi'eenish  pus. 
This  was  quite  sweet,  and  under  the  microscope  showed  booklets  and  signs 
of  hydatid  debris.  On  each  of  these  occasions  the  cyst  had  been  tapped 
through  the  chest- wall ;  but  ten  days  after  the  last  operation,  the  cyst  liav- 
ing  again  refilled,  the  needle  of  the  aspii*ator  was  introduced  through  the 
abdominal  parietes  and  twenty-three  ounces  of  pus  were  evacuated.  The 
operation  set  up  some  local  peritonitis  ;  but  this  was  quickly  reduced  by 
poulticing  and  the  administration  of  six  drops  of  laudanum  three  times  a  da^'. 

After  the  last  operation  the  cyst  did  not  fill  again,  and  when  the  girl 
left  the  hospital  a  month  afterwards,  there  was  slight  curving  of  the  spine 
with  the  convexity  to  the  left ;  the  right  shoulder  and  angle  of  the  scapula 
were  a  little  depressed  ;  the  edge  of  the  liver  was  felt  one  inch  above  the 
umbiHcus,  and  its  upper  border  was  on  a  level  with  the  nipple.  Its  sub- 
stance felt  normal  to  the  touch,  and  there  was  no  distention  or  tenderness 
of  the  belty.  Six  months  afterwards,  when  the  child  was  seen  again,  the 
liver  had  returned  to  its  normal  size  ;  the  spine  was  perfectly  straight ; 
the  shoulders  were  on  the  same  level,  and  no  indication  was  left  that  the 
girl  had  ever  been  ill. 

Injection  of  iodine  after  the  evacuation  of  the  contents  of  the  sac  is  not 
necessary  to  the  success  of  the  operation.  It  is  usually  found  that  simple 
emptying  of  the  cyst  is  sufficient  to  destroy  the  life  of  the  hydatid  and  that 
irritating  injections  are  useless.  In  every  case  the  child  should  be  kept 
very  quiet  for  a  day  or  two  after  the  puncture,  and  a  firm  bandage  should 
be  apphed  to  the  beUy.  It  is  well,  also,  to  give  a  Uttle  opium  at  night,  as 
was  done  in  the  case  above  narrated. 

A  sufficient  time  should  be  allowed  to  elapse  after  evacuating  the  fluid 
before  repeating  the  operation.  The  cyst  will  often  seem  to  be  filling  up 
again  for  a  time  ;  but,  if  left  alone,  it  frequently  subsides  without  further 
interference  and  gradually  becomes  obliterated. 

Dr.  Fagg  has  reported  several  cases  of  hydatid  tumour  of  the  liver  in 
children  which  he  had  treated  by  electrolysis  in  the  manner  recommended 
by  Dr.  Althaus.  The  operation  was  performed  by  passing  two  electrolytic 
needles  into  the  cyst,  one  or  two  inches  apart.  The  needles  were  then  at- 
tached to  two  metallic  wires  both  connected  with  the  negative  pole  of  a 
galvanic  battery  of  ten  cells.  A  moistened  sponge  formed  the  termination 
of  the  positive  pole  ;  and  this  was  placed  on  the  patient's  skin,  at  a  Httle 
distance  from  the  points  of  entrance  of  the  needles.  Its  position  was 
changed  from  time  to  time  during  the  operation.  After  the  cuiTent  had 
passed  for  about  ten  minutes,  the  needles  were  withdrawn  and  adhesive 
plaster  was  applied  to  the  seats  of  puncture. 


HYDATID    OF   THE   LIVER — TREATMENT.  743 

The  operation  was  usually  followed  by  a  little  febrile  disturbance  and 
some  pain  ;  but  no  immediate  effect  upon  the  size  of  the  tumour  was  dis- 
coverable. Indeed,  the  children  were  sent  away  from  the  hospital  in  much 
the  same  state  as  when  they  were  admitted.  But  examination,  after  a 
period  of  months,  usually  detected  considerable  diminution  in  the  dimen- 
sions of  the  cyst.  The  operation  appears,  therefore,  to  be  attended  by  no 
danger  ;  but  its  results  are  too  slow  in  making  themselves  manifest  to  ren- 
der it  suitable  for  adoption  in  private  practice.  With  regard  to  the  modus 
operandi  of  the  procedure.  Dr.  Fagg  suggests  that  the  gradual  subsidence 
of  the  tumour  may  be  due  to  slow  oozing  of  the  hydatid  fluid  through  the 
punctures  made  by  the  needles ;  for  hydatid  fluid  alone,  unaccompanied 
by  ova  or  scolices,  appears  to  be  innocuous  when  extravasated  into  the 
peritoneum. 

If  suppuration  have  occurred  in  the  sac,  and  the  matter  withdrawn  be 
putrid  and  offensive,  the  cyst  must  be  washed  out  frequently  with  a  weak 
antiseptic  solution  ;  opium  should  be  given  to  allay  pain  and  irritation  ;  and 
quinine  in  full  doses,  with  nutritious  diet  and  stimulants,  will  be  required. 


Part  IL 
DISEASES  OF  THE  GENITO-URINARY  ORGANS. 


CHAPTER  I. 

THE  URINE. 


On  account  of  the  difficulty  of  collecting  the  urine  in  very  young  childi*en, 
it  is  seldom  possible  to  estimate  the  average  quantity  passed  in  the  twenty- 
iour  hours.  It  is  not  always  easy  to  obtain  the  quantity  necessary  for  ex- 
amination of  its  chemical  characters. 

In  health,  the  water  is  clear,  light-coloured,  and  of  low  specific  gravity  ; 
but  it  is  subject  to  frequent  variations  on  account  of  the  readiness  with 
which  the  child  responds  to  every  disturbing  agency.  The  quantity  secreted 
is  dependent  upon  certain  conditions,  such  as  : — The  degree  of  blood-press- 
ure in  the  renal  arteries  ;  the  facility  with  which  the  urinary  tubules  dis- 
charge their  contents  ;  and  the  state  of  the  nervous  system  generally.  Also 
upon  the  condition  of  the  other  emunctories  of  the  body,  the  quantity  of 
fluid  taken,  and  lastly,  upon  the  state  of  health  of  the  individual.  Con- 
sequently the  water  passed  varies  greatly  in  amotmt.  Sudden  copious  se- 
cretion may  be  a  temporary  symptom  in  many  cases  of  digestive  derange- 
ment ;  in  particular,  attacks  of  severe  abdominal  pain  are  often  terminated 
by  a  copious  flow  of  almost  colourless  urine  from  the  bladder.  Also,  an 
epileptic  seizure,  an  attack  of  ague,  or  a  fit  of  convulsions  in  the  child  may 
be  followed  by  a  profuse  secretion  of  limpid  urine.  Various  articles  of 
food  seem  to  have  a  direct  action  in  j)romoting  secretion  from  the  kidneys. 
In  some  children  barley-water  has  this  effect ;  and  the  nurse  complains 
that  while  taking  it,  the  child  is  almost  "  constantly  wet."  Again,  certain 
diseases  are  accomj)anied  by  an  increased  flow  of  ru'lne.  Diabetes  mellitus, 
and  diabetes  insipidus  are  in  rare  cases  seen  in  children.  The  former, 
however,  rmcommon  at  any  age  under  puberty,  is  almost  unknown  under 
five  years  of  age.  The  latter  is  sometimes  an  accompaniment  of  gastro-in- 
testinal  disorders,  but  ceases  usually  when  the  digestive  organs  have  been 
put  into  a  better  condition. 

Diminution  in  the  quaatity  of  water  passed  is  the  result  of  many  dif- 
ferent causes,  and  usually  attracts  more  attention  than  the  opposite  condi- 
tion. The  skin  in  some  childi-en  acts  very  freely  ;  and  in  warm  weather  a 
large  proportion  of  the  fluid  may  leave  the  body  by  this  channel.  In  such 
a  case  the  luiue  may  be  very  scanty.     One  morning  in  July  a  child  aged 


THE   UEINE — VAEIATION  IN   QUANTITY.  745 

ten  montlis  was  brought  to  me  on  account  of  the  small  quantity  of  urine 
she  was  passing.  During  the  preceding  twenty-four  hours  she  had  passed 
water  but  once,  and  then  in  very  small  quantity  on  the  evening  before  the 
visit.  The  weather  was  very  warm,  and  the  child  perspired  profusely,  but 
except  for  slight  costiveness  was  and  seemed  perfectly  well.  I  quieted  the 
alarm  of  the  mother,  advised  that  the  child  should  be  given  plenty  of  fluid, 
and  ordered  a  gentle  aperient  to  relieve  the  bowels.  After  this,  the  mother 
was  soon  made  happy  by  seeing  a  more  copious  secretion  of  urine.  The 
amount  of  water  is  also  diminished  by  diarrhoea  and  vomiting,  which  de- 
rangements, as  in  the  preceding  case,  divert  a  certain  quantity  of  water  from 
the  kidneys.  When  the  reduced  secretion  is  due  to  a  watery  flow  from  the 
bowels,  it  may  be  unnoticed  by  the  attendants  ;  but  when  the  symptom  is 
an  accompaniment  of  vomiting,  the  small  quantity  of  water  passed  from  the 
bladder  is  often  a  cause  of  anxiety.  In  cases  of  extreme  prostration  from 
deficient  nourishment  in  infants,  the  secretion  of  urine  is  scanty  and  may 
be  completely  suj^pressed.  Indeed,  Dr.  Parrot  attributes  the  cerebral 
symptoms  which  sometimes  occur  in  such  cases,  and  are  called  "spurious 
hydrocephalus,"  to  toxic  causes,  the  blood  being  charged  with  excrementi- 
tious  matters  which  it  cannot  get  rid  of.  In  the  febrile  state,  the  urinary 
water  is  diminished  in  quantity,  and  is  increased  again  as  the  temperature 
subsides.  There  is,  however,  no  reduction  in  the  solid  constituents  of  the 
urine,  and  the  specific  gravity  is  consequently  raised.  Besides  the  above 
causes  which  act  through  the  system  generally,  other  and  local  causes 
which  interfere  with  the  secreting  function  of  the  kidneys  may  have  the 
same  result.  Thus,  congestion  of  the  kidneys  from  disease  of  the  heart  or 
liver,  and  Bright's  disease,  may  reduce  the  quantity  of  water  to  a  very 
small  amount. 

Variations  occur  not  only  in  the  quantity  of  water  passed  from  the  kid- 
neys, but  also  in  the  amount  of  solid  matters  excreted.  Thus,  in  febrile 
diseases  the  ru'ine  is  not  only  more  concentrated  from  deficiency  of  water, 
but  it  is  richer  in  urea  and  uric  acid,  although  poorer  in  chlorides.  In  health 
the  quantity  of  urea  passed  by  a  child  is  relatively  greater  than  it  is  in  the 
adult.  According  to  Uhle,  children  between  three  and  six  years  of  age 
pass  in  the  twenty-four  hovu'S  one  gi-amme  of  urea  for  each  kilogramme  of 
their  weight.  This  fact  is  important  as  indicating  the  active  metamorpho- 
sis of  the  protein  compounds  of  the  body  which  occurs  in  early  life. 

It  has  been  said  that  the  water  of  a  young  child  in  perfect  health  is 
quite  clear.  In  the  normal  state  it  is  also  slightly  acid.  Very  slight  causes 
will  give  rise  to  an  increase  in  the  amount  of  acid  secreted,  and  the  water 
is  then  apt  to  be  thick  with  lithates.  As  in  older  persons,  the  turbidity 
generally  occurs  as  the  urine  cools  on  standing  ;  but  sometimes  it  is  turbid 
while  still  warm,  and  may  even  be  passed  thick  from  the  bladder.  Infants, 
especially,  sometimes  alarm  their  mothers  by  voiding  water  thick  and 
milky-looking  from  a  profuse  secretion  of  urate  of  soda.  The  appearance 
of  a  deposit  of  lithates  may  be  due  to  two  causes  : — To  increased  secretion 
of  the  salts,  and  to  excess  of  acid  in  the  water.  Young  children  who  are 
habitually  overfed  continually  pass  water  loaded  with  lithates  ;  and  if  they 
are  taking  inordinate  quantities  of  fermentable  material  in  their  food,  the 
amount  of  acid  is  also  greater  than  normal.  Thus,  both  the  causes  which 
conduce  to  turbidity  of  urine  are  present.  During  convalescence  from 
acute  disease  in  a  child,  when  it  is  our  object  to  fui-ther  the  return  of  flesh 
and  strength  by  an  ample  supply  of  nouiishing  food,  and  at  the  same  time 
to  avoid  overburdening  the  digestive  organs  by  an  excess  of  nutritive  ma- 
terial, the  state  of  the  water  offers  a  very  good  index  as  to  whether  the 


746  DISEASE  IN   CHILDREN. 

necessary  quantity  has  been  exceeded.  If  the  child  is  eating  too  much, 
his  water  becomes  at  once  thick  with  Hthates,  and  warns  us  to  make  some 
reduction  in  the  quantity,  or  alteration  in  the  quality  of  his  meals. 

Besides  Hthates,  young  children,  and  even  infants,  may  pass  free  uric 
acid  in  their  water.  This  subject  will  be  considered  afterwards  (see  Cal- 
culus of  Kidney). 

The  urine  in  infants  is  sometimes  noticed  to  be  very  offensive.  This  is 
due  to  a  catarrhal  condition  of  the  bladder,  and  denotes  rapid  decomposi- 
tion of  the  urea.  Another  symptom  sometimes  complained  of  by  the 
mother  is  that  the  water  is  very  dark  in  colom'  and  causes  stains  on  the 
diaper.  This  may  be  the  consequence  of  the  presence  of  bile-pigment  in 
the  urine. 

Albumen  is  often  found  in  the  urine  of  children,  but  must  not  be  looked 
upon  as  in  every  case  indicating  disease  of  the  kidneys.  It  is  seen  in 
many  inflammatory  complaints  and  fevers,  as  in  pneumonia,  dir)htheria, 
measles,  typhoid  fever,  etc.  In  such  cases  it  is  probably  dependent  either 
upon  an  altered  condition  of  the  blood,  when  it  is  an  expression  of  the 
general  disturbance  of  the  system  induced  by  the  illness,  or  upon  an  in- 
fectious nephritis,  which  is  found,  according  to  M.  Bouchard,  in  many 
forms  of  acute  specific  fever.  Again,  a  casual  admixture  of  blood  or  pus 
with  the  urine  may  give  rise  to  the  presence  of  albumen,  as  in  cases  of  ir- 
ritation of  the  urinary  passages  by  calculous  concretions.  Passive  conges- 
tion of  the  kidneys,  such  as  takes  place  in  many  cases  of  heart  disease  and 
in  some  forms  of  bronchitis,  may  be  a  cause  of  the  same  symptom,  and 
the  albumen  may  be  accompanied  by  epithehal  and  bloocl  casts.  But 
in  these  cases  the  presence  of  the  albumen,  and  even  of  the  casts,  is  no 
indication  of  organic  disease  of  the  kidneys.  We  are  only  justified  in 
inferring  the  existence  of  renal  disease  when  we  find  by  the  microscope 
hyaline  or  granular  casts  in  conjunction  with  the  albuminuria.  A  transient 
albuminuria  is  sometimes  met  with,  and  appears  to  be  a  result  of  some 
bodily  derangement  quite  independent  of  renal  disease.  It  may  be  found 
in  school-boys  who  are  preparing  for  examination.  Dr.  Kinnicutt  at- 
tributes it  in  many  cases  to  a  transient  oxaluria  or  lithuria.  It  has  also 
been  seen  in  ague  districts  as  a  consequence  of  malaria.  Intermittent  al- 
bumintu'ia — albumen  being  abundant  one  day,  absent  the  next — is  usually 
due  to  an  admixtui'e  of  secretions,  and  should  lead  us  to  suspect  a  habit  of 
masturbation. 

As  in  older  persons,  the  urine  of  children  and  even  of  infants  may  con- 
tain blood.  This  may  be  poui'ed  out  from  any  part  of  the  urinary  passages. 
When  the  source  of  the  blood  is  the  urethra  or  bladder,  the  two  fluids  are 
passed  separately  without  mingling  together.  Thus,  in  a  case  of  vesical 
calculus,  the  child  passes  first  water  and  then  a  httle  blood  from  the 
bladder.  When  the  two  fluids  are  intimately  blended,  we  are  justified  in 
concluding  that  the  blood  comes  from  the  kidney.  Renal  haemorrhage  is 
not  very  uncommon  in  young  subjects,  and  may  occur  in  large  or  in  small 
quantity.  When  in  large  quantity — in  quantity  sufiicient  to  give  a  dark 
red  colour  to  the  whole  volume  of  Tuine — the  blood  may  be  usually  ascribed 
to  one  of  two  causes  ;  either  to  haemorrhagic  purpura  or  to  mitation  of 
the  kidney  by  calculous  concretions.  In  the  first  case  there  are  signs  of 
haemorrhage  from  other  mucous  passages  and  into  the  skin.  In  the  second, 
the  child  may  complain  of  no  pain,  and  appear,  except  for  the  hfemorrhage, 
to  be  perfectly  well.  In  smaller  quantities,  often  enough  merely  to  give  a 
smoky  tint  to  the  urine,  haematuria  is  seen  in  acute  Bright's  disease,  in 
haemoiThagic  measles,  in  scarlatina,  diphtheria,  and  small-pox  ;  sometimes. 


THE   URINE — HEMATURIA.  747 

also,  in  ague.  Even  after  suppression  of  urine  in  young  children  suffering 
from  inflammatory  diarrhoea,  the  renal  secretion,  when  the  function  of  the 
kidneys  is  restored,  may  contain  blood.  In  fact,  wherever  albumen  is 
present  in  the  mine  blood  may  be  present  as  well.  In  all  such  cases  the 
blood-corpuscles  may  be  recognized  by  the  microscope.  Occasionally,  es- 
pecially in  scarlatina  before  the  appearance  of  albuminuria,  the  urine  *may 
contain  the  colouring  matter  of  the  blood,  but  without  any  of  the  corpuscles 
being  discovered  by  microscopical  examination. 

There  is  a  form  of  hsematuria  which  is  common  in  some  parts  of  Africa, 
especially  in  Egypt  and  the  Cape  of  Good  Hope.  The  haemorrhage  is  due 
to  the  presence  of  the  Bilharzia  hsematobia  (genus  Hematoda).  This  para- 
site is  found  in  the  portal  and  mesenteric  veins,  and  in  the  kidneys  and 
urinai-y  passages.  According  to  Dr.  James  F.  Allen,  almost  every  boy  in 
Natal  suffers  or  has  suffered  from  this  parasite,  for  the  embryos  develope 
in  water  and  abound  in  the  running  streams.  The  giiis,  who  stay  more  at 
home  and  drink  filtered  water,  commonly  escape.  The  creatures  enter  the 
system  by  the  stomach  from  drinking  the  water,  or  by  passing  directly 
into  the  bladder  through  the  urethra  while  the  boy  is  bathing.  Amongst 
the  natives  of  South  Africa  a  practice  is  said  to  prevail,  before  entering  the 
water,  of  tying  a  piece  of  tape  round  the  end  of  the  penis  to  prevent  the 
entrance  of  the  parasite. 

The  hsemorrhage  appears  to  come  from  the  bladder.  After  micturi- 
tion a  little  blood  is  passed  from  the  urethra.  The  quantity  is  often 
only  a  few  drops,  but  may  reach  several  ounces.  It  occurs  on  each  occa- 
sion at  the  end  of  the  flow  of  urine.  Its  passage  is  nearly  always  accom- 
panied by  a  rigor,  and  sometimes  by  pain  and  irritation  referred  to  the 
bladder.  On  examination  of  the  urine  it  is  found  always  to  contain 
blood,  more  or  less  albumen,  and  a  quantity  of  mucus.  In  severe  cases 
its  reaction  is  alkaline,  and  it  contains  triple  phosphate  crystals.  Under 
the  microscope  the  ova  of  the  bilharzia  are  seen  entangled  in  the  blood- 
clots  and  free  among  the  blood-corpuscles.  They  are  j\jj  inch  long,  ovoid 
in  form,  and  have  a  spike  at  one  extremity.  If  the  o^aim  is  broken  under 
the  microscope,  by  pressure  of  the  two  glasses  against  one  another,  the 
living  embryo  may  be  seen  to  emerge  from  its  shell.  It  is  ovoid  in  shape, 
like  the  egg,  is  pointed  at  one  extremity,  and  projecting  from  the  sides  are 
innumerable  cilia,  which  seem  to  be  always  in  motion. 

The  result  of  the  constant  loss  of  blood  soon  manifests  itseK.  The 
boy,  although  taU,  is  pale  and  narrow-chested.  He  has  little  appetite,  is 
listless,  and  shows  no  energy,  either  mental  or  physical.  Childi'en  are  said 
to  begin  to  suffer  from  the  parasite  at  a  very  early  age  ;  but  soon  after 
puberty  the  hsemorrhage  ceases  and  the  patient  recovers.  It  appears 
never  to  be  fatal. 

Dr.  Allen  states  that  internal  treatment  of  every  kind,  although  it 
may  destroy  the  parasite  in  the  blood,  fails  to  influence  the  local  symp- 
toms or  arrest  the  haemorrhage.  To  do  this  local  treatment  is  necessary. 
He  advises  the  injection  into  the  bladder  of  a  saturated  solution  of  san- 
tonine  in  absolute  alcoliol.  Of  this,  a  quantity  varying  from  half  a  drachm 
to  two  drachms  must  be  used  when  the  bladder  is  empty,  and  must  be  re- 
tained as  long  as  possible.  The  injection  sets  up  a  mild  cystitis,  which 
should  be  treated  with  hyoscyamus  and  infusion  of  buchu.  If  the  larger 
quantity  of  santonine  be  used,  the  patient  feels  drunk  from  the  remedy 
affecting  the  brain,  and  the  cystitis  lasts  three  or  four  days,  instead  of 
merely  one  or  two  ;  but  no  other  ill  effects  are  noticed.  The  injection  may 
have  to  be  repeated  several  times,  but  is  invariably  successful  in  the  end. 


748  DISEASE   IX   CHILDEEI?'. 

AfteiTvarcls  santonine  should,  be  given  by  tlie  moutli  to  destroy  any  em- 
bryos remaining  in  the  blood. 

Besides  santonine  other  local  applications  hare  been  suggested.  Iodide 
of  potassium  and  the  liquid  extract  of  male  fern  are  both  well  tolerated 
by  the  bladder.  Dr.  John  Harley  recommends  a  drachm  of  the  fern  ex- 
tract to  be  diluted  "^th  barley-water  and  injected  into  the  bladder. 
Iodide  of  potassium  may  be  used  of  the  strength  of  fifteen  or  twenty 
grains  to  the  fluid  ounce.  Dr.  J.  Wortabet  speaks  in  favour  of  the  in- 
ternal administration  of  oil  of  tui'pentine,  and  records  a  case  in  which 
a  complete  cure  was  effected  by  di-achm  doses  of  this  remedy. 

Retention  of  urine  is  not  very  common  in  young  children.  It  may, 
however,  be  induced  by  mechanical  causes.  Thus,  some  httle  boys  have 
a  very  long  prepuce,  with  a  naiTOW  opening,  through  which  the  urine  is 
forced  with  difficulty.  This  extra-urethi'al  strictui'e  forms  a  great  obstacle 
to  the  complete  emptying  of  the  bladder,  and  may  be  a  cause  of  serious 
injury  to  the  health.  Cases  are  occasionally  met  with  in  which  dilatation 
of  the  bladder,  ui'eters,  and  jDelves  of  the  kidneys  have  been  induced  by 
such  long-continued  retention  and  pressiu'e.  Another  common  consecjuence 
of  the  straining  efforts  which  usually  accompany  the  attempt  to  evacuate 
the  bladder  is  prolapsus  ani.  Eetention  of  ui'ine  may  also  result  from 
the  presence  of  a  calculus,  which,  becoming  impacted  in  the  Tirethi-a,  pre- 
vents the  passage  of  water  fi'om  the  bladder.  I  have  even  known  such 
an  accident  to  lead  to  mpture  of  the  membranous  pari  of  the  lu-ethi-a, 
and  extravasation  of  the  urine.  Again,  irritation  of  the  rectum  by  worms 
may  be  a  cause  of  sj)asmodic  retention  of  lu'ine.  Violent  blows  upon 
the  lower  part  of  the  abdomen  may  produce  a  temporary  jDaralysis  of  the 
bladder  and  retention.  Lastly,  in  some  cases  of  febrile  disease,  such  as 
typhoid  fever,  we  occasionally  find  distention  of  the  bladder  from  atony 
of  the  muscular  coat. 

Incontinence  of  urine,  or  enui-esis,  as  it  is  called,  is  a  much  more  familiar 
symptom  in  young  childi'en  than  retention.  Involuoitaiy  joassage  of  the 
water  may  occur  in  the  night  or  in  the  day ;  and  sometimes  the  child  is 
unable  to  control  his  bladder  either  by  day  or  by  night.  This  distressing 
infirmity  is  fai"  from  uncommon.  It  may  date  from  bii-th,  or  may  be  ac- 
C|uh'ed  later.  "WTien  acquii-ed,  its  first  occui'rence  has  been  attributed  to 
fright ;  but  it  is  a  popular  impression  that  aU  nervous  derangements  ai'e 
excited  by  some  shock  to  the  nervous  system,  and  too  much  importance 
must  not  be  attached  to  this  explanation.  In  cases  where  it  is  not  due  to 
manifest  weakness  of  mind  or  pui-e  laziness  of  body,  and  where  no  disor- 
dered condition  is  present  to  which  the  incontinence  can  be  attributed,  we 
may  sometimes,  by  cai'eful  examination,  detect  some  external  soui'ce  of  iiTi- 
tation  which  requires  removal.  Thus,  the  ra'ine  may  be  habitually  too 
acid,  and  deposit  crystals  of  uric  acid  ;  there  may  be  phimosis,  allowing 
of  accumulation  of  irritating  secretion  beneath  the  prepuce  ;  the  ur'ethral 
orifice  may  be  narrowed  extei-naUy  ;  the  prepuce  may  be  wholly  or  ia  part 
adherent  to  the  gians  ;  or  again,  gi'eat  irritation  may  be  excited  in  the 
neighbour-hood  by  thi'ead-worms  in  the  rectum.  In  a  sensitive  cMld  iiTi- 
tation  at  some  distance  from  the  bladder  may  act  as  the  exciting  cause. 
Thus,  enuT'esis  may  be  the  consequence  of  chi'onic  disease  of  the  hij)- joint, 
and  may  cease  when,  by  rest  and  proj^er  mechanical  appHances,  the  irTita- 
tion  of  the  joint  has  been  subdued.  Sometimes  the  most  careful  investi- 
gation faUs  to  discover  any  such  exciting  cause.  The  incompetence  is 
then  attributed  to  general  irritabihty  of  the  nervous  system,  or  to  "  sj)inal 
ii'ritation," 


THE   URINE — INCONTINElSrCE — EISTITRESIS.  749 

The  meclianism  of  the  phenomenon  is  well  understood.  Owing  to 
causes  which  may  or  may  not  be  capable  of  explanation,  there  is  excessive 
irritability  of  the  muscular  fibres  of  the  bladder.  Under  normal  condi- 
tions the  bladder  is  closed  by  the  contraction  of  the  sphincter  vesicse, 
whose  office  it  is  to  resist  the  action  of  the  fibres  forming  the  muscular 
coat.  If  necessary,  the  involuntary  contraction  of  the  sphincter  can  be  re- 
inforced by  the  exercise  of  the  will.  In  the  more  common  form  of  incon- 
tinence, where  the  involuntary  passage  of  urine  takes  place  at  night  only, 
the  mitabihty  of  the  muscular  coat  is  exaggerated,  and  the  resistance  of 
the  sphincter  is  relatively  deficient.  There  is  no  atony  of  the  sphincter, 
but  on  account  of  the  increased  pressure  against  which  it  has  to  contend 
it  requires  to  be  strengthened  by  voluntary  agency.  During  sleep  the 
agency  of  the  will  is  removed,  and  the  sphincter  can  no  longer  effectually 
resist  the  action  of  the  irritable  muscular  fibres,  so  that  the  contents  of 
the  bladder  are  discharged.  In  cases  where,  in  addition  to  the  abnormal 
excitability  of  the  muscular  coat  there  is  a  certain  degree  of  atony  of  the 
sphincter,  the  patient  has  little  control  over  his  bladder  even  during  the 
daytime.  Micturition  is  frequent,  and  when  the  desire  to  pass  water 
manifests  itself,  it  can  hardly  be  resisted  even  for  a  few  seconds. 

This  derangement  has  been  classed  amongst  the  neuroses,  with  epi- 
lepsy, chorea,  and  other  similar  affections.  According  to  Trousseau,  it  is 
often  found  in  families  prone  to  ej^ilepsy,  and  may  thus  be  a  hereditary 
failing.  It  cannot,  however,  be  always  attributed  to  a  faulty  condition  of 
the  nervous  system.  In  many  instances  it  appears  rather  to  be  due  to  the 
active  reflex  sensibihty  which  is  normal  to  the  healthy  child.  These  are 
the  cases  in  which  the  enuresis  is  manifestly  the  consequence  of  some  ex- 
ternal source  of  irritation,  and  ceases  when  this  is  removed.  "We  know 
how  promptly,  in  health,  the  nervous  sj^stem  of  a  child  responds  to  reflex 
stimuli,  and  we  constantly  have  occasion  to  observe  the  perturbation  into 
which  the  whole  system  is  thrown  by  the  action  of  some  external  initant. 
No  doubt  the  class  of  cases  in  which  the  power  of  controlhng  the  bladder 
returns  "of  itself,"  more  or  less  suddenly,  are  cases  of  this  kind.  As  the 
child  growls  older,  the  extreme  sensitiveness  of  his  nervous  system  to  ex- 
ternal impressions  becomes  dulled.  The  only  variety  of  enui'esis  which 
can  be  classed  justly  amongst  the  true  nervous  affections  is  that  in  w^hich 
the  incontinence  is  hereditary,  or  occurs  in  famihes  subject  to  epilepsy  or 
other  form  of  neui'otic  disease,'  or  is  apparently  a  consequence  of  nervous 
instability  without  any  external  cause  being  discovered  to  which  the  faulty 
action  can  be  attributed. 

Emrresis,  when  acquu^ed  after  infancy,  is  generally  observed  first  be- 
tween the  thu'd  and  fourth  years.  It  is  seen  as  often  amongst  the  strong 
and  robust  children  as  amongst  the  thin  and  delicate ;  but  is,  perhaps, 
more  common  in  boys  than  in  guis.  The  more  obstinate  forms  of  this  in- 
firmity are,  however,  more  common  in  the  female  sex,  probably  because 
in  them  the  complaint  is  less  often  the  consequence  of  external  imtation. 
In  ordinary  cases  the  accident  occurs  only  at  night,  and  even  then  not 
every  night.  Often  for  a  week  or  more  the  bed  remains  dry.  Then  it  is 
wetted  regularly  for  several  nights  in  succession,  and  sometimes  the  acci- 
dent occui's  on  the  same  night  several  times.  It  is  usually  during  the 
earty  hours,  or  later  towards  daybreak,  that  the  child's  bladder  seems  to 
be  least  under  control ;  and  it  is  at  these  times  that  the  incontinence  is 

^  It  must  not  be  forgotten  that  nocturnal  incontinence  of  urine  may  be  tbe  only 
sign  of  the  occurrence  of  true  epileptic  attacks  in  the  night. 


750  DISEASE  IIT   CHILDKElSr. 

usually  manifested.  After  continuing  for  a  variable  time  the  infirmity  may 
disappear  without  treatment.  The  periods  of  second  dentition  and  of 
puberty  are  popularly  supposed  to  be  sometimes  marked  by  this  favoura- 
ble change. 

In  the  treatment  of  enuresis  our  first  care  should  be  to  search  for  any 
source  of  external  irritation.  If  this  can  be  found,  its  removal  forms  the 
first  step  to  a  cure,  and  indeed  the  case  may  require  no  further  treatment. 
Thus,  the  removal  of  an  elongated  prepuce ;  the  separation  of  adhesions 
between  the  prepuce  and  the  glans ;  the  expulsions  of  thread-worms,  or 
suitable  medicines  by  which  too  great  acidity  of  urine  has  been  remedied — - 
all  of  these  measures  have  been  followed  by  immediate  rehef  from  this 
distressing  complaint.  Sometimes,  however,  such  measures  have  to  be 
supplemented  by  others,  directed  to  lessen  the  abnormal  irritability  of 
the  muscular  coat  of  the  bladder.  In  all  such  cases  care  should  be  taken 
that  the  child  drinks  Httle  towards  evening,  and  empties  his  bladder  com- 
pletely before  he  goes  to  bed.  Moreover,  if  the  incontinence  occur  in 
the  early  hours  of  the  night,  the  nui-se  should  be  directed  to  take  up  the 
child  and  see  that  his  bladder  is  properly  relieved  before  herself  retiring 
to  rest. 

Of  medicines  which  diminish  irritability,  belladonna  takes  the  first 
place  ;  but  it  is  important  to  be  aware  that  this  remedy,  to  be  effectual, 
must  be  given  in  full  doses.  Children  have  a  very  remarkable  tolerance 
for  belladonna,  and  will  often  take  it  in  surprising  quantities  before  any 
of  the  physiological  effects  of  the  drug  can  be  produced.  In  obstinate 
cases  of  enuresis  the  medicine  should  be  pushed  so  as  to  produce  dilata- 
tion of  the  pupils  with  slight  dryness  of  the  throat.  In  children  of  four 
or  five  years  of  age  it  is  best  to  begin  with  twenty-five  or  thirty  drops  of 
the  tincture  of  belladonna  given  three  times  in  the  day,  and  to  increase 
the  dose  by  five  droj)S  every  second  or  third  day,  of  course  watching  the 
effect.  Ergot  is  another  remedy  which  is  often  very  successful.  For  a 
child  of  the  same  age  twenty  drops  of  the  liquid  extract  may  be  given 
several  times  in  the  day.  Bromide  of  potassium,  benzoic  acid  (dose,  five 
^to  ten  grains),  and  benzoate  of  ammonia,  digitalis,  borax,  cantharides, 
camphor,  and  chloral,  have  all  been  recommended  as  specifics  in  this  com- 
plaint. Sometimes  a  combination  of  several  drugs  seems  to  be  more 
effectual  than  one  given  alone.  I  have  lately  cured  a  little  girl,  aged  four 
years,  who  had  resisted  all  other  treatment,  with  the  following  draught 
given  three  times  in  the  day : — 

J^.  Tinct.  bellad 3  j. 

Potas.  bromidi gr.  X. 

Inf.  digitahs 3  ij. 

Aquam ■ ad.  |  ss. 

M.  Ft.  haustus. 

When  the  incontinence  continues  in  the  day  as  well  as  at  night,  strychi 
nia  should  be  combined  with  the  sedative  so  as  to  give  tone  to  the  feeble 
sphincter.  In  these  cases,  too,  cauterization  of  the  neck  of  the  bladder 
with  a  strong  solution  of  nitrate  of  silver  (3j.-  3  j-  to  the  ounce  of  water), 
has  been  found  successful. 

Besides  drugs,  other  measures  have  been  employed  in  obstinate  cases. 
Thus,  abstinence  from  animal  food,  including  meat-broths,  has  been  found 
to  succeed  in  cases  where  drugs  and  other  treatment  had  failed.  In  some 
country  places  in  England  a  popular  remedy  consists  in  wrapping  the  feet 


THE   URINE — ENURESIS — TREATMENT.  751 

of  the  patient  at  niglit  in  clotlis  wrung  out  of  cold  water.     I  have  never 
used  this  remedy,  but  it  is  said  to  be  an  effectual  one. 

Electricity  has  been  lately  employed  with  advantage  in  these  cases. 
One  electrode  in  the  shape  of  a  spinal  disk,  connected  with  the  positive 
pole  of  the  battery,  is  applied  to  the  lumbar  region  of  the  spine.  A  second 
electrode  is  placed  above  the  pubes  or  in  the  perinseum.  A  weak  current 
is  then  passed  for  several  minutes  once  a  day.  It  is  said  that  under  this 
treatment  immediate  improvement  is  noticed,  and  that  a  complete  cure 
follows  within  a  fortnight. 


CHAPTER  n. 

CHEONIC  BRIGHT'S  DISEASE. 

Bbight's  disease,  both  in  the  acute  and  chronic  stage,  is  seen  in  the  child. 
The  acute  form  is,  however,  the  more  generally  met  with  on  account  of 
the  frequency  with  which  scarlatina  occurs  in  early  Ufe,  and  the  tendency 
of  this  specific  fever  to  be  complicated  by  acute  renal  disease  and  dropsy. 

Causation. — It  is  no  doubt  to  scarlet  fever  that  the  large  proportion  of 
cases  of  acute  Bright's  disease  in  the  young  child  must  be  referred.  Still, 
it  is  not  very  uncommon  to  meet  with  acute  renal  dropsy  in  children  who 
are  without  any  history  of  scarlatina,  who  show  no  signs  of  desquamation 
of  the  skin,  and  in  whom  no  cause  for  the  symptoms  but  recent  exposure 
to  cold  can  be  detected.  The  practice  of  short-coating  infants  of  a  few 
months  old,  regardless  of  the  state  of  the  weather,  which  prevails  in  this 
country,  is  no  doubt  often  answerable  for  this  as  for  other  catarrhal  dis- 
orders in  early  life.  A  child  of  a  few  months  old,  who  has  been  recently 
short-coated,  is  taken  out  on  a  cold  damp  day  almost  naked  from  his  waist 
downwards  ;  for  his  scanty  skirts  afford  httle  protection  to  the  lower  part 
of  his  body.  A  day  or  two  afterwards  he  is  noticed  to  be  pale  and  puff^- 
looking  about  the  face  ;  he  vomits,  and  his  beUy  and  legs  begin  to  swell. 
At  the  same  time  his  urine  is  scanty,  high-coloured,  perhaps  smoky,  and 
throws  down  a  precipitate  of  albumen  on  boiling.  This  is  not  a  rare  in- 
stance, but  occurs  sufficiently  often  to  be  a  not  unfamiliar  experience  to 
most  medical  practitioners.  It  has  been  suggested  that  there  is  a  connec- 
tion between  eczema  and  kidney  disease  in  children  ;  and  eczema  of  the 
genitals  has  been  said  to  be  often  followed  by  fatal  renal  symptoms ;  but 
I  cannot  corroborate  this  statement  by  my  own  experience. 

The  form  of  Bright's  disease  met  with  during  the  first  two  or  three 
years  of  life  is  generally  the  acute  variety.  Infants,  however,  as  well  as 
older  children,  may  suffer  from  the  disease  in  a  chronic  form  ;  but  no  doubt 
this  is  in  many  cases  a  rehc  of  a  previous  acute  attack.  Certain  diseases  may 
lay  the  foundation  of  chronic  renal  mischief,  viz.,  scarlatina,  measles,  small- 
pox, scrofulous  disease  of  bone  and  of  other  tissues  causing  prolonged 
suppuration,  ague,  diphtheria,  and  (in  infants)  intestinal  catarrh. 

Either  the  contracted  granular  kidney  (interstitial  nephritis),  the  large 
fatty  kidney  (chronic  parenchymatous  nephritis),  or  the  amyloid  kidney 
may  be  met  with  in  early  Hfe  ;  but  the  first  is  rare  at  this  age,  although  it 
appears  to  be  sometimes  set  up  by  obstruction  to  the  escape  of  urine,  either 
from  impacted  calculus  or  some  other  cause ;  and  the  fibroid  interstitial 
growth  may  then  be  profuse. 

The  large  fatty  kidney  is  more  commonly  met  with  than  the  preceding. 
This  lesion  is  usually  the  result  of  acute  Bright's  disease,  and  commonly 
dates  from  an  attack  of  scarlatina.  It  may,  however,  be  chronic  fi'om  the 
first  and  arise  as  a  consequence  of  long-standing  suppuration. 

The  amyloid  kidney  is  far  from  rare.     Childi-en,  especially  those  who 


CHEONIC   bright' S   DISEASE — MOEBID   AE"ATOMY.  753 

are  subjects  of  the  scrofulous  cachexia,  are  very  liable  to  suffer  from  pro- 
fuse purulent  discharges.  If  the  discharge  is  continued  for  a  long  time 
together,  it  will  often  lead  to  amyloid  degeneration  of  organs  in  which  the 
kidneys  as  weU  as  the  liver  and  spleen  are  involved. 

Morbid  Anatomy. — It  is  unnecessary  in  a  special  treatise,  such  as  the 
present,  to  enter  minutely  into  the  pathological  changes  to  be  met  with  in 
the  kidney  in  cases  of  chronic  Bright's  disease.  Theee  changes  are  the 
same  in  the  child  as  they  are  in  the  adult,  and  are  described  at  length  in 
all  the  text-books.  It  may  be  sufficient  to  recall  to  the  reader's  memory 
the  principal  points  connected  with  each  of  these  three  varieties. 

The  contracted  granidar  kidney  is,  as  its  name  implies,  considerably  re- 
duced in  size.  Its  capsule  is  thickened  and  adherent ;  its  surface  is  nodu- 
lar, and  its  colour  a  deep  red.  On  section  we  find  the  cortex  thin  ;  the 
meduUa  atrophied,  and  the  substance  dense.  The  essence  of  the  disease 
consists  in  a  great  hyperplasia  of  the  connective  tissue  of  the  organ.  This 
fibroid  overgrowth  passes  inwards  from  the  surface  along  the  course  of  the 
intertubular  vessels,  and  involves  more  or  less  regularly  the  whole  depth 
of  the  cortex.  It  thickens  the  Malpighian  capsules,  and  compresses  the 
capillary  tufts  and  the  convoluted  tubes.  The  small  arteries  are  thickened 
and  their  calibre  reduced.  As  the  increase  of  fibrous  tissue  is  not  evenly 
distributed,  but  is  much  greater  in  some  spots  than  it  is  in  others,  the 
amount  of  injury  to  the  kidney  substance  varies  ;  and  while  some  tubes  are 
much  atrophied  and  shrunken,  others  escape  almost  entirely.  The  convolut- 
ed tubes  are  often  denuded  of  their  epithelial  lining,  and  are  sometimes  seen 
under  the  microscope  to  be  stuffed  with  fatty  debris  or  with  hyaline  casts. 
In  some  places  the  denuded  tubules  dilate  here  and  there  into  cysts  ;  in 
other  places  they  atrophy  and  may  be  converted  into  mere  threads.  The 
straight  tubes  in  the  pyramids  are  comparatively  little  altered.  The 
shrinking  of  the  kidney  and  its  granular  appearance  are  late  changes,  and 
are  due  to  the  contraction  of  the  new  fibroid  material. 

In  the  large  ivhite  fatty  kidney  it  is  the  tubular  structure  which  is  prin- 
cipally involved — especially  the  convoluted  tubes  in  the  cortex.  The  kid- 
ney is  larger  than  natural,  and  its  capsule  can  be  readily  detached.  The 
cortical  part  of  the  kidney,  to  swelling  of  which  the  increase  in  size  is  due, 
is  perfectly  smooth  on  the  surface  and  pale  in  colour.  No  ramifying  ca- 
pillaries are  to  be  seen,  but  here  and  there  red  specks  from  extravasation  of 
blood  dot  the  anaemic  surface. 

On  section  the  cortex  has  the  same  paUid  tint,  and  contrasts  curiously 
with  the  cones  of  the  pyramids  which  stiU  retain  their  healthy  colour.  By 
the  microscope  the  convoluted  tubes  are  seen  distended  to  twice  their 
natural  size  ;  and  their  epithelial  lining  is  swollen  and  granular  looking.. 
The  tubes  often  contain  granular  debris  and  fibrinous  exudation,  and,, 
sometimes,  extravasated  blood  from  a  ruptiu-ed  Malpighian  body. 

After  a  time  the  epithelial  cells  in  the  tubes  become  disintegrated 
and  are  removed,  and  sometimes  increase  of  the  interstitial  connective  tis- 
sue takes  place  as  in  the  preceding  variety.  The  kidney  then  shrinks  and 
may  become  granular  on  the  surface,  but  stiU  continues  very  pale  in 
colour. 

Amyloid  disease  in  the  kidney  is  usually  associated  with  the  same  de- 
generation of  the  liver  and  spleen.  If  the  degeneration  is  marked,  the  or- 
gan is  increased  in  size  and  has  a  waxy,  pale,  and  slightly  translucent  ap- 
pearance. The  amyloid  change  begins,  as  a  rule,  in  the  vessels  of  the 
Malpighian  tufts,  but  soon  spreads  from  these  to  the  vessels  (both  afferent 
and  efferent),  the  vascular  plexuses  (both  intertubular  and  interlobular), 
48 


754  DISEASE  IN   CHILDREN". 

and  the  urinary  tubules.  This  condition  is  often  combined  with  other 
forms  of  renal  degeneration. 

Symptoms. — The  symptoms  of  acute  BrigMs  disease  have  been  already 
considered  in  the  chapter  on  Scarlatina. 

The  chronic  disease  in  its  earlier  stages,  and  until  it  gives  rise  to  dropsy, 
is  accompanied  by  few  symptoms,  and,  indeed,  is  probably  often  over- 
looked. The  child  is  pale,  dull,  and  listless.  He  complains  of  his  head, 
and  is  capricious  in  his  eating.  Sometimes  he  passes  large  quantities  of 
water,  which — especially  if  the  disease  be  of  the  granular  variety — may  be 
of  normal  density,  and  contain  no  albumen.  Even  when  dropsy  occm's, 
albuminuria  may  be  absent  or  trifling. 

A  little  boy,  aged  one  year  and  ten  months,  with  sixteen  teeth,  began 
gradually  to  get  pooiiy.  He  gTew  pale,  seemed  heavy  and  sleepj^,  and 
vomited  often  after  his  meals.  After  this  state  of  things  had  continued 
for  a  month  his  face  became  puffy,  his  eyehds  swelled,  and  general  oedema 
appeared  over  the  body  and  hmbs.  "When  taken  into  the  East  London 
Children's  Hospital,  no  disease  of  any  organ  could  be  discovered  ;  the  liver 
and  spleen  were  of  natural  size  ;  the  heart  was  healthy,  and  the  tempera- 
tm-e  was  normal.  There  was  no  sign  of  peeling  of  the  skin.  For  some 
days  no  urine  could  be  collected,  for  the  quantity-  was  scanty,  and  the 
child  passed  it  all  in  his  cot.  At  last  some  was  obtained,  but  no  albumen 
was  discovered,  nor  could  any  casts  of  tubes  be  seen.  Purges  and  dia- 
phoretics soon  dispersed  the  cedema,  and  the  child  then  took  iron  and 
cod-liver  oil.  The  sickness  continued  for  some  weeks  after  the  oedema 
had  disappeared.  The  ui-ine  was  examined  several  times,  but  no  albumen 
was  ever  found. 

The  dropsy  in  this  case  was  not  the  result  of  ansemia  and  weakness,  for 
the  child  was  not  at  aU  emaciated,  and  his  mucous  membranes  were  fairly 
red.  The  oedema  had  all  the  characters  of  kidney  dropsy.  It  began  in 
the  face,  and  was  distributed  very  generally  over  the  body.  A  similar 
form  of  dropsy  without  albuminuria  or  casts  is  sometimes  found  as  a  sequel 
of  scarlet  fever. 

In  some  cases  Bright's  disease  appears  to  be  quite  latent  until  oedema 
occurs. 

A  little  boy,  aged  twenty-one  months,  with  twelve  teeth,  came  into  the 
hospital,  under  my  care,  with  slight  dropsy  which  had  lasted  for  a  week. 
The  child  had  never  had  scarlatina  or  measles  ;  and  had  been  a  fairly 
healthy  boy,  although  for  some  weeks  his  bowels  had  been  relaxed,  and 
the  discharges  offensive.  He  had  suffered,  shortly  before  admission,  from 
ulceration  of  the  mouth,  which,  however,  had  been  soon  recovered  from. 
He  coughed,  and  his  appetite  was  poor. 

When  the  child  was  first  seen,  the  oedema,  although  slight,  was  gen- 
eral. The  urine  was  scanty  and  alkahne,  and  contained  one-sixteenth  of 
albumen.  There  was  a  deposit  of  triple  phosphate  crystals,  with  many 
large  and  small  hyaline  casts,  and  some  granular  casts.  The  temperature 
at  first  was  normal,  but  after  a  few  days  rose  to  101.4°  ;  the  child  began 
to  cough ;  he  was  then  violently  convulsed,  and  died  a  few  hours  after- 
wards. 

On  examination  of  the  body  the  lower  part  of  the  right  lung  was  found 
to  be  consohdated.  The  left  kidney  was  absent.  The  right  measm-ed 
three  inches  in  length  by  two  and  three-quarters  in  breadth.  The  capsule 
was  adherent,  and  on  removing  it  small  portions  of  renal  substance  were 
torn  away  with  it.  The  surface  of  the  organ  was  very  granular  and  irreg- 
idar.     On  section  the  tint  was  paler  than  natural ;  the  pyramids  were  less 


CHEONIC   BEIGHT'S   DISEASE — SYMPTOMS.  755 

red  tliau  iu  the  liealthy  subject,  and  the  cortex  was  thinned.  The  whole 
kidney  felt  very  dense,  and  its  substance  seemed  unusually  tough.  Un- 
fortunately, the  organ  was  not  exanained  microscopically,  but  there  can  be 
httle  doubt  that  this  was  a  case  of  granular  kidney,  and  that  it  was  of 
some  standing,  although  in  so  young  a  child. 

Sometimes  the  only  sign  of  the  chronic  disease  may  be  the  marked 
pallor  of  the  complexion,  with  frequent  attacks  of  headache  and  vomiting, 
lasting  for  several  days,  or  a  week  or  more  at  a  time.  Sometimes,  as  in 
the  adult,  the  sight  becomes  affected  from  albuminous  retinitis.  Such 
cases,  without  a  careful  examination  of  the  ui-ine,  may  be  mistaken  for 
cerebral  tumour.  Indeed,  a  history  of  frequent  attacks  of  headache  and 
vertigo,  accompanied  by  vomiting,  and  of  gradual  failure  of  the  sight,  is 
very  suspicious  of  a  tumour  of  the  brain.  In  all  such  cases,  therefore,  it 
is  very  important  to  make  a  careful  examination  of  the  water  for  albumen, 
and  to  search  the  deposit  frequently  for  casts  of  tubes.  The  skin  is  gen- 
erally dry  and  rough,  and  is  often  markedly  inelastic,  so  that  when  pinched 
uj)  into  folds  it  remains  "vviinkled,  and  does  not  smooth  out  cjuickly,  as  a 
healthy  skin  would  do.  This  is  especially  the  case  in  infants  and  the 
younger  children.  Purpura  is  sometimes  found  to  be  an  accompaniment 
of  the  renal  mischief  ;  but  whether  it  is  excited  by  the  nephritis,  or,  as 
Dr.  Gee  suggests,  arises  with  it  as  a  consequence  of  some  bodily  condition 
common  to  both,  is  uncertain.  Purpuric  patches  may  be  seen  on  the 
skin,  and  blood  may  be  passed  mth  the  urine  and  stools. 

Usually,  acute  exacerbations  occur  from  time  to  time.  These  mostty 
follow  a  chill,  and  are  accompanied  by  scanty  secretion  of  urine,  puffiness 
of  the  face,  and  oedema  of  the  limbs.  The  water  is  then  albuminous,  and 
may  be  smoky,  or  even  red,  from  admixtiu'e  with  blood.  The  headache 
is  often  severe,  vomiting  may  be  distressing,  the  dropsy  may  be  marked, 
and  convulsions  may  occur,  with  di'owsiness  or  coma.  Sometimes  the 
attack  is  comphcated  with  pericarditis  or  pleurisy,  as  it  is  in  the  adult 
When  the  acute  symptoms  subside,  the  amount  of  albumen  gTadually 
diminishes,  and  after  a  time  may  quite  disappear  from  the  urine.  There 
may  be  then  httle  left  to  show  that  the  kidneys  are  not  healthy,  but  re- 
peated examinations  of  the  urine  mil  perhaps  disclose  a  slight  deposit, 
with  fragments  of  granular  or  hyaline  casts. 

In  cases  of  acute  renal  di'opsy,  it  is  common  enough  to  hear  that  the 
child  had  had  scarlatina  some  months  or  years  previously,  followed  by 
dropsy  ;  that  he  had  completely  recovered  to  all  appearance  ;  but  that  lately, 
having  been  exposed  to  cold,  he  had  begun  to  vomit  and  the  oedema  had 
reappeared.  In  such  a  case  it  is  reasonable  to  conclude  that  the  restora- 
tion of  the  kidneys  was  not  so  complete  as  had  been  suj)posed.  Some- 
times the  acute  exacerbation  is  preceded  by  pallor,  wasting,  vomiting,  gen- 
eral weariness,  and  a  look  of  ill-health.  The  child  passes  water  much 
more  frequently''  than  natural  in  the  day,  and  at  night  may  wet  his  bed. 

A  boy,  aged  fourteen,  was  in  the  East  London  Children's  Hospital, 
under  the  care  of  my  colleague,  Dr.  Donkin.  The  patient  had  had  mea- 
sles and  scarlatina.  He  was  said  to  be  very  dull  at  his  lessons.  His  se- 
ci*etion  of  urine  was  large,  and  he  seemed  to  have  a  difficulty  in  holding 
it.  A  month  before  his  admission  the  boy  had  had  a  rash  over  the  body 
which  had  lasted  a  fortnight.  He  had  then  begTin  to  vomit  his  food, 
complained  of  pain  all  over,  looked  paUid  and  weakly,  and  was  manifestly 
losing  flesh. 

When  admitted,  he  was  pale  and  thin  ;  seemed  very  fretful,  and  looked 
ill.     His  temperature  was  normal.     His  urine  was  acid,  had  a  specific 


756  DISEASE  IIN"   CHILDREIN". 

gi'a-sdty  of  1.015,  and  contained  no  albumen  or  sugar.  Tlie  boy  coughed 
a  little,  but  nothing  positive  was  noted  about  his  chest.  There  was  no 
sign  of  peeling  of  the  skin. 

After  beiDg  in  the  hospital  for  about  three  weeks,  during  which  time 
he  had  decidedly  improved  and  had  gained  flesh,  the  lad  was  allowed  to  go 
out  into  the  garden.  The  same  evening  his  face  looked  puffy,  and  his  legs 
were  found  to  pit  on  pressui^e.  His  temperatui'e  that  night  was  normal. 
On  the  following  day  the  oedema  was  marked.  He  vomited  several  times  ; 
eomj)lained  of  severe  headache,  and  seemed  very  stupid  and  stubborn. 
His  temperature  rose  that  evening  to  100°.  His  water  was  smoky,  con- 
tained a  sixth  of  albumen,  and  had  a  liocculent  deposit  which  showed 
under  the  microscope  many  gi-anular  casts.  On  the  third  day  his  tem- 
peratui'e  was  101.8^  both  morning  and  evening,  and  he  had  a  series  of  con- 
vulsive fits,  followed  by  drowsiness  which  lasted  for  twenty-foui'  hours. 
His  temperature  then  became  normal  again,  and  the  oedema  began  to  de- 
cline. His  water  was  discoloured  Tvith  blood  for  several  days,  and  the  al- 
bumen and  casts  only  slowly  disappeared  ;  but  before  the  boy's  dischai'ge, 
his  urine,  except  for  a  shght  haziness  with  the  cold  nitric  acid  test,  had 
again  become  normal. 

In  this  case  the  history  and  the  previous  symj^toms,  as  well  as  the 
rapidity  with  which  the  renal  phenomena  followed  the  chill,  pointed  to 
some  chronic  affection  of  the  kidneys,  although  no  albumen  was  found  in 
the  urine  on  the  lad's  admission  into  the  hospital.  Perhaps  in  many  of 
these  cases  careful  and  repeated  examination  of  the  water  would  be  more 
successful  in  finding  albumen.  A  great  deal  depends,  too,  on  the  way  in 
which  the  examination  is  conducted.  Boiling  the  ruine  and  afterwards 
adding  a  few  drops  of  nitric  acid  is  a  very  coarse  test ;  and  if  the  propor- 
tion of  albumen  is  small,  it  ma}-  easily  escape  detection  by  this  means.  A 
far  more  dehcate  test  is  that  of  floating  cold  urine  from  a  pipette  upon  the 
surface  of  strong  nitric  acid  placed  in  the  bottom  of  a  test-tube.  Albumen 
should  never  be  excluded  until  the  uiine  has  been  tested  by  this  process, 
and  allowed  to  stand  for  a  quarter  of  an  hour  in  order  to  give  the  light, 
cloudy  disk  of  albumen  time  to  form  upon  the  top  of  the  acid.  Still,  it 
cannot  be  denied  that,  however  carefully  the  examination  may  have  been 
conducted,  it  will  often  be  impossible  to  discover  the  presence  of  even  a 
trace  of  albumen  between  the  attacks  of  acute  disease.  The  child,  how- 
ever, is  not  well.  He  often  remains  pale  and  thin,  loses  all  ajDpetite,  and 
is  nervous  and  excitable.  His  dishke  to  eating  is  a  source  of  great  anx- 
iety to  his  parents,  and,  indeed,  it  is  often  most  difficult  to  persuade  him 
to  take  even  a  minimum  c[uantity  of  food. 

The  water  may  be  secreted  in  fair  amount,  often,  indeed,  is  copious ; 
but  its  specific  gTa^ity  is  low.  It  is  usually  very  acid,  and  sometimes  uric 
acid  sand  is  seen  at  the  bottom  of  the  chamber-pan.  Perhaps  on  this  ac- 
count there  is  often  a  difficulty  in  holding  the  water,  especially  at  night. 
There  can  be. little  doubt  that,  although  giving  rise  to  no  very  characteris- 
tic symptoms,  the  kidneys  are  not  healthy,  and  that  their  depiu-ative  func- 
tions are  imperfectly  performed. 

A  case  which  I  saw  some  time  ago,  in  consultation  with  Mi'.  E.  Stanley 
Smith,  affords  a  good  example  of  the  insidious  progress  of  gTanulai*  kid- 
ney disease  in  the  child. 

A  little  boy,  aged  nine  years,  of  excitable,  nervous  temperament,  in- 
heriting a  tendency  to  epilepsy  on  his  father's  side,  and  to  phthisis  on  his 
mother's,  was  said  to  have  been  poorly  for  eighteen  months.  His  indis- 
position had  begun  with  an  attack  of  "fever"  in  which  the  temperature 


CHRONIC   BBIGHT's   DISEASE — SYMPTOMS.  757 

rose  every  night  to  102°  or  103°  ;  he  had  severe  headache,  and  was  at 
times  slightly  deliiious.  He  was  ill  for  a  week.  Since  that  time  he  had  had 
similar  attacks,  but  milder  in  character.  He  was  said  often  to  look  pasty 
and  sallow  in  the  face,  and  to  seem  languid  and  inclined  to  mope,  although 
when  pretty  well  in  health  he  was  lively  and  active,  and  his  spirits  were 
high.  "WTien  poorly,  his  urine  would  contain  a  trace  of  albumen  ;  it  was 
always  very  acid,  and  often  contained  large  quantities  of  uric  acid  sand. 
No  casts  were  ever  seen  at  that  time.  The  boy  was  wasting  slowly,  al- 
though his  appetite  was  good.  He  slej)t  badly,  and  was  always  restless  at 
night.  His  bowels  were  usually  costive,  and  after  an  a^^erient  he  passed 
much  mucus.  He  stammered  at  times,  and  the  muscles  of  his  face  would 
often  twitch.  The  specimen  of  his  urine  shown  to  me  was  very  acid  and 
of  specific  gravity  1.024.  It  contained  no  trace  of  albumen  ;  but  there  was 
a  copious  deposit  of  uric  acid  sand.  After  I  had  seen  the  boy  he  did  not 
improve.  The  albumen  became  more  frequent,  and  granular  casts  and 
blood-corpuscles  began  to  be  discovered.  On  one  occasion,  a  hyahne  cast 
was  seen.  There  was  never  any  trace  of  oedema,  and  his  heart  and  pulse 
were  normal. 

In  this  case  the  feverish  attacks  were  no  doubt  attacks  of  acute  gastric 
catarrh.  Apart  from  this  s^^mptom,  which  may  have  been  only  an  acci- 
dental feature  in  the  case,  and  had  probably  no  other  influence  than  that 
of  aggravating  the  tendency  to  flatulence  and  acidity,  there  can  be  little 
doubt  that  the  boy  was  suffering  fi'om  granular  kidney.  It  seems  prob- 
able that  there  is  a  connection  between  the  passage  of  red  sand  and  the 
kidney  degeneration,  for  I  have  noticed  the  association  in  other  instances. 
Certainly,  in  a  case  where  a  child  habitually  passes  large  quantities  of  uric 
acid  crystals,  I  should  be  disposed  to  fear  the  occurrence  of  Bright's 
disease  ;  and  the  occasional  presence  of  a  trace  of  albumen  would  add 
strength  to  my  apprehensions. 

The  after-course  of  this  boy's  case  is  interesting.  He  was  sent  to  the 
south  of  France,  and  passed  a  considerable  time  at  Cannes.  Dr.  Gr.  C. 
Bright,  under  whose  care  the  boy  was  placed,  informs  me  that  on  arriving 
at  Cannes  the  urine  contained  one-eighth  of  albumen,  and  that  its  sediment 
showed  numerous  gTanular  casts  and  much  renal  epithelium.  After  a  stay 
of  nine  months  the  water  had  ceased  to  contain  albumen  or  casts,  although 
there  was  still  an  occasional  deposit  of  uiic  acid  sand.  Its  density  was 
habituaUy  1.025. 

In  this  boy  there  was  no  hypertrophy  of  the  heart ;  and  no  abnormal 
tension  of  the  pulse  was  ever  noticed.  Although  the  albumen  ceased  for  a 
time  to  be  present  in  the  urine,  it  is  impossible  to  suppose  that  all  structural 
lesion  of  the  kidneys  had  disappeared.  This  is  no  doubt  another  instance  of 
renal  disease  without  albuminiuia,  or  rather,  with  intermittent  albuminui-ia, 
for  that  albumen  and  casts  will  eventually  reappear  can  scarcely  be  doubted. 
It  is  curious  that  a  sister  of  the  patient  suffered  from  similar  symptoms. 

When  the  kidney  is  the  seat  of  amjdoid  degeneration  there  is  no  neces- 
sary albuminuria,  and  even  increased  secretion  of  urine  is  not  an  invariable 
symptom.  Dr.  j\L  Litten  has  published  the  detads  of  four  cases  which  place 
the  truth  of  this  statement  beyond  a  doubt.  In  a  case  which  was  under  my 
own  care — ahttle  gu-1  seven  years  of  age— general  oedema  had  been  jDresent 
for  two  years,  succeeding  to  an  attack  of  scarlatina.  The  child  suffered 
from  angular  curvatui-e  of  the  sjoine  of  some  standing.  Her  liver  and  spleen 
were  much  enlarged,  and  felt  very  dense  and  resisting.  Enlarged  mesen- 
teric glands  could  be  detected  in  the  abdomen  on  deep  pressure.  The  aver- 
age quantity  of  water  passed  in  the  twenty-four  houi'S  was  twelve  ounces. 


758  DISEASE  IlSr   CHILDKElSr. 

It  had  a  copious  deposit  of  lithates.  There  was  never  any  albumen,  nor 
could  any  casts  be  discovered  under  the  microscope.  Its  density  varied 
from  1.020  to  1.025. 

In  this  case,  where  the  liver  and  spleen  were  evidently  the  seat  of  amy- 
loid degeneration  with  probable  enlargement  of  the  same  kind  in  the  mesen- 
teric glands,  it  is  difficult  to  suppose  that  the  kidneys  had  entirely  escaped 
any  participation  in  the  disease.  Probably  only  an  early  stage  of  the  degen- 
eration is  characterised  by  absence  of  albuminuria  and  a  scanty  secretion 
of  urine.  As  the  disease  becomes  more  advanced,  the  quantity  of  water 
secreted  is  more  copious  ;  it  contains  albumen — at  first  in  small  quantities, 
afterwards  in  considerable  amount,  and  the  specific  gravity  of  the  fluid  is 
high.  Eenal  epithelium  with  hyahne,  granular,  and  often  fatty  casts,  may 
be  seen  by  the  microscope  in  the  deposit. 

There  is  a  form  of  renal  disease  from  which  children  of  various  ages  are 
prone  to  suffer,  which  appears  to  be  in  many  cases  a  temporary  ailment,  but 
which  produces  very  definite  symptoms.  The  disorder  is  indicated  by  pal- 
lor, weakness,  wasting,  constipation,  sometimes  by  sickness,  and  in  every 
case  by  a  remarkable  absence  of  the  natural  elasticity  of  the  skin.  This  loss 
of  elasticity  is  a  very  characteristic  symptom.  When  the  skin  of  the  abdomen 
is  pinched  up,  it  remains  wrinkled,  or  only  slowly  recovers  its  smoothness. 
On  examining  the  water  no  albumen  is  found,  but  the  quantity  is  small  and 
its  specific  gravity  is  low.  Evidently  sufficient  solids  are  not  discharged  by 
the  kidneys ;  and  the  retention  of  effete  matters  in  the  system,  owmg  to  this 
renal  inadequacy,  is  apparently  the  cause  of  the  symptoms.  A  case  has 
been  already  referred  to  in  the  chapter  on  enteric  fever,  in  which  a  child 
convalescent  from  that  disease  passed  for  many  days  no  more  than  eight  or 
ten  ounces  of  urine  in  the  twenty-four  hours,  with  a  specific  gravity  of  1.015. 
He  was  excessively  feeble,  stupid,  and  lethargic ;  his  skin  was  markedly 
inelastic  ;  and  it  was  only  after  the  secretion  of  water  had  increased,  and  its 
density  had  risen,  that  his  physical  and  mental  weakness  passed  off,  and  the 
normal  elasticity  of  his  skin  was  restored.  It  was  calculated  that  this  boy 
secreted  by  the  kidneys,  in  the  twenty-four  hours,  no  more  than  two  and 
three-quarter  gi'ains  of  solid  matters  for  every  pound  of  his  weight — a 
quantity  which  is  of  com-se  considerably  below  the  average  amount. 

The  quantity  of  urea  passed  daily  in  childhood  is  proportionately  greater 
than  it  is  in  adult  life.  In  the  East  London  Children's  Hospital  I  caused 
the  urine  of  thirteen  selected  cases,  in  which  kidney  disease  could  be  ex- 
cluded, to  be  collected  for  the  twenty-four  hours ;  and  calculating  roughly 
from  the  specific  gravity,  it  appeared  that  the  average  quantity  of  solid  mat- 
ters passed  from  the  kidneys  in  this  time  was  five  grains  for  every  pound  of 
the  child's  weight.  The  ages  of  the  children  were  between  four  and  ten 
years.  In  the  adult  the  daily  quantity  has  been  estimated  by  Dr.  Parkes 
to  be  three  and  a  half  grains  per  pound  weight.  My  experiment  was  of 
course  a  rough  one,  making  no  pretensions  to  mathematical  accuracy ; 
but  the  conclusion  arrived  at  was,  no  doubt,  sufficiently  near  the  truth  to 
be  useful  as  a  guide  in  practice. 

I  believe  quite  young  children  sometimes  suffer  from  a  temporary  de- 
ficiency in  the  secretion  of  urea,  although,  as  it  is  impossible  to  collect  the 
whole  quantity  of  urine  passed,  I  can  bring  forward  no  positive  evidence 
in  support  of  this  statement.  Some  time  ago  I  saw  a  male  infant  seven 
weeks  old,  who  was  brought  up  at  the  breast  of  a  very  healthy  mother. 
He  had  been  perfectly  well  for  the  first  four  weeks  after  his  birth.  He 
had  then  begun  to  vomit  sour  fluid  and  curd,  and  at  the  same  time  his 
bowels  had  become  obstinately  confined.     This  state  of  things  had  con- 


CHEONIC   BEIGHT'S   DISEASE — SYMPTOMS — DIAGNOSIS.       759 

tinued  for  three  weeks,  the  infant  becoming  thinner,  and  his  bowels  only- 
acting  after  an  aperient  or  enema.  On  the  morning  of  the  visit  he  had 
just  been  relieved  after  five  days'  constipation.  The  child  was  thin  but  did 
not  look  iU.  No  sign  of  disease  could  be  observed  about  any  part  of  his 
body,  and  the  belly  was  not  retracted.  The  skin  was  excessively  inelastic. 
It  lay  on  the  abdomen  in  loose  Avrinkles,  and  when  pinched  up,  the  folds 
remained  exactly  as  they  were  left  without  smoothing  out.  No  tu'ine  could 
be  obtained  for  examination.  An  aperient  powder  was  given,  and  small 
doses  of  the  infusion  of  senna  with  glycerine  were  ordered  three  times  a 
day.  After  two  months  the  elasticity  of  the  skin  had  partially  returned, 
and  eventually  it  was  perfectly  restored.  The  return  of  elasticity  in  the 
skin  was  accompanied  by  progressive  improvement  in  the  condition  of 
the  child.  The  vomiting  ceased  soon  after  treatment  was  begun  ;  but  the 
costive  state  of  the  bowels  remained  a  trouble  for  a  considerable  time. 

The  above  case  represents  a  form  of  derangement  which  is  sometimes 
met  with  in  the  infant.  It  is  not  an  ordinary  case  of  gastric  catarrh,  such 
as  is  common  in  early  infancy,  for  in  this  disorder  the  elasticity  of  the 
skin  is  in  no  way  interfered  with.  Nausea  and  vomiting,  constipation,  a 
dry,  inelastic  skin,  and  slight  albuminuria,  form  a  combination  of  symptoms 
constantly  met  with  in  cases  of  deficient  renal  secretion  in  children  whose 
water  can  be  tested,  and  also  in  adults,  according  to  Sir  Andrew  Clark.  It 
seems,  therefore,  at  any  rate  possible  that  diminished  functional  activity  of 
the  kidneys  may  produce  similar  symptoms  in  the  infant.  Kjellberg  has 
observed  a  frequent  connection  between  intestinal  catarrh  and  parenchy- 
matous inflammation  of  the  kidney  in  the  young  child,  and  mentions  as 
one  of  the  characteristic  symptoms  of  the  kidney  complication  a  dry, 
tough  skin  without  elasticity.  In  every  case,  therefore,  where  we  find  this 
condition  of  the  skin  in  a  young  subject,  we  should  examine  very  carefully 
for  signs  of  renal  disease. 

Diagnosis. — In  examining  for  albumen  a  specimen  of  the  urine  passed 
after  the  first  meal  in  the  day  should  be  taken,  and  the  fluid  should  be 
afterwards  set  aside  in  a  conical  glass  in  order  that  solid  particles,  if  any, 
may  subside.  The  deposit  should  be  taken  up  carefully  with  a  pipette, 
and  placed  in  a  shallow  cell  made  by  cementing  a  thin  ring  of  glass  on  to 
the  ordinary  microscope  shde.  This,  covered  with  a  thin  glass,  should  be 
carefully  searched  for  casts  of  tubes. 

The  complete  absence  of  albuminuria  and  casts  is  no  sufficient  indica- 
tion that  the  kidneys  are  perfectly  healthy.  It  seems  probable,  from  the 
cases  which  have  been  narrated,  that  a  certain  amount  of  disease  may 
exist  in  the  kidneys  although  the  urine  presents  the  characters  of  health  ; 
and  it  is  now  an  established  fact  that  considerable  amyloid  degeneration 
may  exist  in  the  organ  without  its  presence  being  betrayed  by  any 
abnoi'mal  condition  of  the  urinary  secretion.  In  all  cases  where  renal 
disease  is  suspected,  although  no  albuminuria  can  be  discovered,  it  is  well 
to  cause  the  whole  amount  of  water  passed  in  the  twenty-four  hours  to  be 
collected.  A  calculation  can  then  be  made  from  the  specific  gravity  of  the 
fluid,  by  means  of  Professor  Haughton's  tables,'  which  will  give  a  rough 
estimate  of  the  quantity  of  urea  being  excreted  in  the  course  of  the  day 
and  night.  If  at  the  same  time  we  ascertain  the  weiglit  of  the  child,  the 
amount  of  sohd  matters  passed  for  each  pound  of  his  weight  can  be  easily^ 
calculated.  A  healthy  child  shoidd  pass  daily  between  five  and  six  grains 
of  urea  per  pound  of  his  weight. 

'  Given  in  the  Medical  Times  and  Gazette  for  October  27,  1864. 


760  DISEASE  Ilf   CHILDREN. 

If  albuminuria  and  casts  can  be  detected,  it  is  not  always  easy  to 
decide  upon  the  natm-e  of  the  kidney  lesion.  The  presence  of  amyloid 
degenei-ation  of  the  liver  and  spleen  renders  the  same  condition  of  the 
kidney  very  probable.  A  chronic  form  of  Bright's  disease  succeeding  to 
an  acute  attack,  such  as  an  attack  of  scarlatinous  nephritis,  is  usually  due 
to  the  fatty  kidney  (chronic  parenchymatous  nephritis)  ;  but  this  form  of 
Blight's  disease  may  also,  like  the  contracted  granular  kidney,  begin  in- 
sidiously. If  albuminuria  and  casts  are  present  without  dropsy,  the  kidney 
is  probably  granular. 

The  constant  passage  of  red  sand  from  the  kidneys  is  to  be  regarded 
with  anxiety,  for  in  such  cases  Bright's  disease  may  ])e  developed  after  a 
time,  as  in  the  case  of  the  child  before  referred  to. 

Prognosis. — When  Bright's  disease  is  established  in  the  child,  i.e., 
when  albumen  and  casts  are  constantly  present,  the  prognosis  is  very  un- 
favourable ;  for  such  a  condition,  if  it  do  not  destroy  life  unassisted,  must 
greatly  increase  the  danger  of  any  intercurrent  malady.  Such  children,  if 
attacked  by  pneumonia  or  pleurisy,  are  very  likely  to  die.  In  the  case  of 
amyloid  kidney  the  prognosis  is,  perhaps,  less  unfavourable  than  in  the 
other  forms  of  Bright's  disease  ;  for  it  seems  possible  that,  if  the  chronic 
suppurative  process  which  has  excited  the  structural  change  can  be  re- 
moved by  operation  or  otherwise,  all  the  symptoms  of  kidney  derangement 
may  disappear.  That  such  a  happy  termination  to  the  illness  is  possible, 
is  proved  by  a  case  published  by  Mr.  BarweU,  in  which,  after  the  removal 
of  a  scrofulous  joint,  albuminuria  and  casts  ceased  after  a  time  to  be  found 
in  the  urine,  and  the  child  grew  up  into  a  strong,  healthy  woman.  From 
this  case  we  may  learn  that  the  existence  of  amyloid  disease  of  the  kidneys 
is  no  bar  to  the  successful  issue  of  operative  procedures  ;  but  that  on  the 
contrary,  surgical  interference  in  such  cases  is  urgently  called  for. 

Mere  renal  inadequacy,  without  albuminuria  or  history  of  acute  Bright's 
disease,  is  probably  in  most  cases  a  merely  temporary  condition  which, 
under  suitalDle  treatment,  may  be  rapidly  recovered  from.  But  if  a  child 
habitually  pass  large  quantities  of  uric  acid  sand,  or  if  he  have  more  than 
one  attack  of  acute  Bright's  disease,  even  although  the  urine  have  been 
normal  in  the  interval,  and  return  to  a  healthy  state  after  the  symptoms 
have  passed  away,  we  should  regard  the  possibility  of  his  ultimately  devel- 
oping manifest  disease  of  the  kidneys  as  one  not  to  be  entirely  excluded 
from  consideration. 

Treutment — In  cases  where  we  find  deficient  secretion  of  urea,  without 
albuminuria  or  signs  of  organic  renal  disease,  we  should  take  care  to  un- 
load the  bowels  by  free  purgatives,  unless,  as  in  the  case  before  referred 
to,  the  child  be  just  convalescent  from  typhoid  fever.  In  ordinary  cases 
gray  powder  and  jalapine  may  be  given  in  doses  suitable  to  the  age  of  the 
child.  He  should  be  made  to  drink  freely  of  some  harmless  fluid,  and 
thin  barley-water  sweetened  and  flavoured  with  vanilla  is  very  useful  as  a 
mucilaginous  diuretic.  The  aperient  should  be  repeated  as  often  as  seems 
desirable  to  ensure  complete  relief  to  the  bowels  ;  and  in  addition  the  pa- 
tient may  take  a  mixture  containing  citrate  of  potash  with  tincture  of  nux 
vomica,  or  a  few  drops  of  tincture  of  rhubarb.  The  child  should  not  be 
allowed  too  much  animal  food.  Fish  is  better  for  him  than  butcher's 
meat,  and  he  should  take  plenty  of  milk  and  green  vegetables.  If  broth 
be  allowed  it  must  be  perfectly  fresh,  and  not  be  made  from  "stock."  If 
there  be  anaemia  in  these  cases,  iron  can  be  given  after  a  time. 

If  a  child  be  the  subject  of  undoubted  renal,  disease,  it  is  of  the  utmost 
.  importance  to  attend  to  the  working  of  functions  the  impaired  action  of 


CHRONIC   BEIGHT'S   DISEASE — TREATMENT.  .     761 

which  will  increase  the  labour  of  the  kidneys.  The  skin  should  be  en- 
couraged to  act  by  a  daily  tepid  bath,  by  warm  clothing,  and  by  careful 
avoidance  of  the  causes  of  chill.  The  patient  should  be  dressed  from  head 
to  foot  in  flannel  or  other  warm  wooUen  material,  and  should  take  regular 
exercise  in  the  open  air.  The  bowels,  if  inclined  to  be  costive,  should  be 
kept  relieved  by  aperients  ;  and  small  doses  of  senna,  or  podophylline  and 
belladonna,  or  a  nightly  dose  of  Hunyadi  Janos  water,  as  recommended  in 
the  chapter  on  constipation,  are  very  useful.  The  patient  should  eat 
sparingly  of  flesh  meat ;  but  milk  and  fish  are  suitable,  and  a  due  propor- 
tion of  farinaceous  and  vegetable  matters  should  be  included  in  his  diet. 
If  the  amount  of  albumen  is  great,  it  may  be  advisable  to  put  the  child 
for  a  time  upon  a  diet  consisting  merely  of  milk  and  bread.  Certainly  in 
such  cases  animal  food  should  be  taken  with  caution,  and  should  not  be 
allowed  every  day. 

Climate  is  a  matter  of  very  great  importance  in  cases  of  chronic  renal 
disease.  If  possible,  the  child  should  be  removed  for  the  winter  to  a 
neighbourhood  where  the  air  is  fairly  warm  and  dry.  Here  he  can  pass 
his  time  out  of  doors  without  risk  of  chill,  and  the  beneficial  influence  of 
such  a  change  is  often  very  remarkable.  The  albumen  and  casts  may 
quite  disappear  from  the  urine,  aiad  for  the  time,  at  least,  the  health  may 
seem  to  be  completely  restored. 

Of  medicines,  iron  is  the  best  remedy,  and  the  perchloride  the  best 
preparation.  This  salt  has  a  distinctly  diuretic  action,  especially  if  well 
diluted  with  water.  Its  influence  in  promoting  the  renal  secretion  is  in- 
creased by  the  addition  of  dilute  acetic  acid  and  solution  of  acetate  of 
ammonia,  as  suggested  by  the  late  Dr.  Basham  (see  page  730).  The 
draught  may  be  sweetened  by  glycerine  or  by  a  few  drops  of  spirits  of 
chloroform. 

If  an  attack  of  acute  Bright's  disease  come  on,  with  elevation  of  tem- 
perature, oedema,  and  head  symptoms,  relief  may  be  speedily  obtained  in 
the  majority  of  cases  by  free  purgation  and  packing  in  a  blanket  bath,  as 
recommended  in  cases  of  scarlatinous  nephritis  (see  page  46).  The  in- 
fluence of  energetic  purgation,  too,  is  most  striking ;  nothing  relieves  head 
symptoms  so  quickly  as  a  good  sweeping  aperient.  A  useful  form  is  the 
combination  of  compound  jalap  powder  with  compound  scammony  pow- 
der. Enough  should  be  given  to  produce  four  or  five  copious  evacuations. 
Elaterium  is  too  uncertain  in  its  action  to  be  suitable  for  children. 

If  the  albuminuria  persist  after  an  attack  of  the  acute  disease,  iron 
should  be  given  directly  the  temperature  becomes  normal.  The  drug  may 
be  usefully  combined  with  strychnia  and  arsenic.  A  child  of  eight  years 
old  may  take  three  times  a  day  twenty  drops  of  the  liq.  ferri  perchloridi' 
with  two  of  liq.  strychniae  and  four  of  liq.  arsenicahs  in  a  large  wineglass- 
ful  of  water  sweetened  with  glycerine.  This  medicine  should  be  given 
directly  after  food,  lest  it  cause  nausea.  Gallic  acid  has  been  recommended, 
but  on  account  of  its  tendency  to  constipate  often  seems  to  do  more  harm 
than  good.  The  first  necessity  in  these  cases  is  to  promote  free  excretion 
from  the  bowels.  If  this  function  be  interfered  with,  no  medicine  can  be 
of  much  value.  On  this  account  iron  often  seems  to  act  better  if  given  in 
the  form  of  the  sulphate  with  sulphate  of  magnesia  and  dilute  sulphuric 
acid  ;  but  the  other  form  is  equally,  if  not  more,  serviceable,  if  care  be 
taken  to  keep  the  bowels  free.  In  obstinate  cases  fuschine  (the  chloro- 
hydrate  of  rosaniline)  is  said  to  hasten  the  disap^Dearance  of  the  albumen 
after  an  acute  attack.  This  drug  may  be  given  to  a  child  in  doses  of  from 
two  to  five  grains.      It  tinges  the  urine  of  a  reddish  colour.     Kecently, 


762  DISEASE   IN   CHILDEEN. 

chloral  hydrate  has  been  given  with  the  same  object.  It  can  be  prescribed 
to  a  child  of  five  years  of  age  in  doses  of  three  or  four  grains  three  times  a 
day. 

A  fatal  ending  in  uncomphcated  cases  of  chronic  Bright's  disease  from 
exhaustion  and  dropsy  must  be  rare  in  the  child.  I  cannot  remember 
having  met  with  such  a  case  except  in  connection  with  amyloid  disease, 
and  there  the  general  distribution  of  the  degeneration  fui-nishes  other  rea- 
sons for  the  condition  of  the  patient.  Chronic  kidney  disease  is  usually 
fatal  in  young  subjects  through  the  occurrence  of  some  inflammatory  com- 
plication. Pleurisy  and  pneumonia  in  such  cases  are  excessively  danger- 
ous. They  must  be  treated  with  stimulants  and  counter-irritation.  The 
chest  and  back  should  be  repeatedly  dry-cupped  ;  the  bowels  should  be 
fi-eely  acted  upon,  and  the  strength  of  the  patient  must  be  supported  by 
suitable  quantities  of  misweetened  gin. 

If  the  dropsy  in  any  case  be  copious,  it  must  be  treated  as  recommended 
under  the  head  of  Scarlatinous  Nephritis  (see  page  46).  Pilocarpine  is 
sometimes  useful  in  these  cases.  Occasionally  it  may  be  necessary  to 
puncture  the  legs  with  Dr.  Southey's  trocars. 


CHAPTER  III. 

CALCULUS   OF  THE   KIDNEY. 

The  occasional  passage  of  reel  sand  from  the  bladder  in  childliood  is  not 
an  uncommon  occurrence.  As  a  rule,  little  pathological  significance  is  to 
be  attached  to  it.  Uric  acid  is  very  liable  to  be  formed  if  food  is  taken 
largely  in  excess  of  the  requirements  of  the  system.  It  is  not  even  neces- 
sary that  the  food  be  nitrogenous  to  produce  this  result ;  for  as  Dr.  Garrod 
has  observed,  it  is  a  mistake  to  suppose  that  an  animal  diet  must  tend 
more  to  the  formation  of  uric  acid  than  a  vegetable  one.  It  must  be  re- 
membered, however,  that  the  presence  in  the  uiine  of  a  deposit  of  lithic 
acid  or  its  salts  is  no  proof  that  any  excess  of  the  acid  is  formed  and  se- 
creted. The  increase  is  often  only  apparent.  When  the  urine  is  scanty 
from  deficiency  of  water,  the  uric  acid  may  appear  to  be  in  excess.  Again,^ 
great  acidity  of  urine  may  cause  a  deposit  of  uric  acid.  The  neutral 
lithates  are  more  soluble  than  the  acid  lithates,  and  these  than  uric  acid. 
Therefore,  if  the  urine  is  full  of  neutral  salts,  any  cause  which  vnll  remove 
a  part  or  the  whole  of  the  base  will  throw  down  a  precipitate.  The  addi- 
tion of  acid  will  do  this.  Thus,  if  very  acid  urine  be  secreted  into  the 
bladder  when  this  ah-eady  contains  a  neutral  or  alkaline  urine,  the  acid 
abstracts  the  base  from  the  neutral  salts  and  a  deposit  is  formed  at  once. 

The  uric  acid  appears  in  the  urine  in  the  form  of  crystalUne  grains,  or, 
if  very  abundant,  as  a  red  sandy  deposit.  In  infants  and  young  children 
there  appears  to  be  a  special  tendency  to  uric  acid  deposits ;  and  these 
may  be  thrown  down  in  the  kidney  itself  before  the  urine  has  passed  into 
the  bladder.  The  so-called  uric  acid  infarctions  of  the  kidney,  forming' 
yeUovnsh  red  streaks  running  in  the  direction  of  the  pyramids,  may  be 
found  after  death  in  the  youngest  infants — in  them,  indeed,  more  fre- 
quently than  in  older  children.  These  infarctions  consist  of  amorj)hous 
urate  of  ammonia  mixed  with  crystals  of  uric  acid,  and  occupy  the  straight 
tubes  of  the  pjTamids.  They  do  not,  any  more  than  the  sandy  deposits 
in  the  urine,  indicate  the  existence  of  kidney  disease.  They  are  due  to  ex- 
cessive feeding,  or,  in  young  babies,  to  the  increased  metamorphosis  of 
tissue  elements  which  must  take  place  after  birth  in  consequence  of  the 
newly-inaugurated  processes  of  digestion,  respiration,  and  generation  of 
heat. 

A  deposit  of  crystals  of  uric  acid  may  be  formed  at  any  part  of  the 
urinary  apparatus.  The  lu'inary  tubules  often  contain  such  collections. 
A  particle  of  crystallised  m'ic  acid  is  deposited  in  the  cortical  j^art  of  the 
gland.  It  may  remain  in  this  sjDot,  or  may  pass  further  down  the  urinary 
apparatus  into  the  straight  tubes  or  the  jDelvis  of  the  kidney.  In  either 
case  it  is  apt  to  become  enlarged  by  successive  additions  to  the  original 
nucleus.  Great  irritation  is  often  caused  by  the  passage  of  these  frag- 
ments, and  even  minute  crystalline  particles,  if  with  sharp  angles,  may  so 
scratch  and  wound  the  delicate  membrane  lining  the  fine  tubules  of  the 


764  DISEASE  IN   CHILDEEN. 

kidney  and  calices  of  the  pyramids,  as  to  be  a  cause  of  hsemorrhage.  In 
spite,  however,  of  the  frequency  of  sandy  deposits,  the  ui-ine  in  childhood 
does  not,  as  often  as  might  be  expected,  contain  an  admixture  of  blood. 
At  least,  an  intimate  blending  of  the  blood  with  the  urine,  such  as  is  known 
to  be  characteristic  of  renal  hsemorrhage,  is  in  the  child  comparatively 
rare. 

Besides  uric  acid,  oxalate  of  lime  concretion^  are  not  uncommon  in 
children.  These  are  dependent  upon  the  same  causes  as  the  preceding. 
According  to  Schenck,  uric  acid  is  converted  by  oxidation  into  oxaluric 
acid,  and  this  is  readily  decomposed  by  both  acids  and  alkalies,  sj)litting  up 
into  oxalic  acid  and  urea.  The  oxalic  acid  at  once  combines  with  the  base 
of  any  lime  salt  which  may  be  present,  and  is  precipitated  as  the  insoluble 
oxalate  of  lime.  This  process  may  take  place  in  any  part  of  the  urinary 
passages,  and  if  crystals  of  oxalate  of  lime  are  found  in  warm  urine  before 
the  fluid  has  had  time  to  cool,  it  may  be  inferred  that  they  have  been 
formed  inside  the  body,  and  we  should  think  of  the  possibility  of  calculus. 

Besides  uric  acid  and  oxalate  of  lime  concretions,  small  calculi  of  the 
urates  of  ammonia  and  soda  may  be  formed.  Often  the  concretions  are 
compound,  and  contain  a  nucleus  of  uric  acid  round  which  oxalate  of  lime 
or  urate  of  ammonia  has  been  deposited.  If  the  concretion  be  encrusted 
with  phosphates,  it  is  a  sign. that  irritation  has  been  set  up  in  the  bladder 
or  pelvis  of  the  kidney. 

Causation. — Some  children  have  a  greater  tendency  than  others  to  the 
deposition  of  uric  acid  in  the  urinary  passages.  This  tendency  often  runs 
in  families,  and  is  then  commonly  associated  with  the  gouty  constitution. 
The  form  of  scrofula  which  is  connected  with  a  stout,  heavy  build,  and 
much  flabbiness  of  flesh,  is  also  said  to  be  distinguished  by  a  similar  ten- 
dency. In  both  of  these  cases  there  is  no  doubt  an  inclination  to  gastric 
disturbances  and  the  generation  of  acid  in  the  stomach.  The  actual  deposi- 
tion of  uric  acid  crystals  in  the  form  of  sand  and  gravel  is  apt  to  be  excited 
by  excessive  or  unwholesome  diet — especially  of  indulgence  in  the  more 
fermentable  articles  of  food.  Thus,  large  quantities  of  farinaceous  sub- 
stances, particularly  where  the  starch  is  imperfectly  cooked,  and  of  fruit 
or  sweets,  may  give  rise  to  the  formation  of  acid  in  the  digestive  organs. 
Too  close  confinement  to  the  house,  especially  in  cold  damp  weather,  may 
in  some  subjects  load  the  urine  with  uric  acid  or  its  compounds.  Indeed, 
any  influence  which  interferes  with  the  assimilative  processes,  such  as  fear, 
giief,  and  other  depressing  passions  of  the  mind,  over-fatigue  of  the  body, 
temporary  febrile  ailments — all  these  causes  may  determine  a  precipita- 
tion of  uric  acid  in  the  urinary  passages.  According  to  Dr.  Garrod,  con- 
centration of  the  urine  from  deficiency  in  the  amount  of  water  excreted  by 
the  kidneys  is  a  common  cause  of  gravel  in  early  life.  La  these  cases  the 
habitual  passage  of  red  sand  is  compatible  with  every  evidence  of  good 
health.  Amongst  other  cases  he  refers  to  that  of  a  boy  aged  five  and  a 
half  j-ears,  whose  urine  from  day  to  day  contained  either  uric  acid  crys- 
tals or  deposited  a  copious  red  sediment  almost  immediately  after  it  was 
voided.  The  whole  quantity  of  urine  passed  in  the  twenty-four  hours  was 
only  sixteen  ounces,  with  a  specific  gravity  of  1,031.  Directly  the  child 
was  made  to  take  more  fluid,  so  as  to  increase  the  quantity  of  water  passed 
from  the  kidneys,  uric  acid  ceased  to  be  discoverable  in  the  secretion. 

Symptoms. — The  passage  of  the  ordinary  lithates  is  no  more  a  cause  of 
irritation  in  the  young  child  than  it  is  in  the  adult.  A  baby  may  jDass 
water  thick  and  milky  from  the  presence  of  urates  without  showing  that 
he  is  sensible  of  any  unusual  sensation  while  voiding  the  contents  of  his 


CALCULUS   OF  THE   KIDNEY — SYMPTOMS.  765 

bladder.  When,  however,  free  uric  acid  is  discharged  with  the  urine,  we 
usually  notice  signs  of  discomfort.  Water  is  passed  more  frequently  and 
in  smaller  quantities.  The  child  screams  and  strains  during  its  passage, 
and,  if  old  enough,  complains  of  pain  in  the  urethra.  In  these  cases  we 
shall  often  find  red  gritty  matter  on  the  infant's  diaper,  or  red  sand  at  the 
bottom  of  the  chamber-pan.  Sometimes,  this  ii-ritation  is  a  cause  of  wet- 
ting the  bed  at  night,  and  therefore  the  water  should  always  be  examined 
for  uric  acid  crystals  in  cases  of  noctiu-nal  incontinence  of  urine. 

While  still  in  the  kidney  these  concretions  may  give  rise  to  few  or  even 
no  symptoms.  Sometimes  the  only  sign  of  their  presence  is  a  more  or 
less  copious  admixture  of  blood  with  the  urinary  water.  If  the  concre- 
tions are  of  some  size,  the  haemorrhage  may  be  accompanied  by  attacks  of 
pain  in  the  kidney.  Hsematuria  in  children,  especially  in  infants,  is  usuaUy 
to  be  attributed  to  this  cause.  In  the  case  of  infants  a  stain  of  bright 
blood  is  noticed  on  the  wet  diaper.  In  older  children  the  blood  is  inti- 
mately blended  with  the  urine,  and  the  mixture  may  have  a  deep  red  colour 
if  the  haemorrhage  be  copious.  The  urine  is  acid,  deposits  albumen  on 
boiling,  and  often  crystals  of  uric  acid  can  be  discovered  with  the  abun- 
dant blood-corpuscles  under  the  microscope. 

A  little  girl,  aged  four  years,  the  ninth  child  of  healthy  parents,  was 
admitted  into  the  East  Loudon  Children's  Hospital,  No  history  of  gout 
could  be  discovered  in  the  family.  Of  the  other  children,  four  had  died, 
one  from  whoojDing-cough,  the  others  of  brain  disease,  nature  unknown. 
The  patient  herself  had  always  been  a  healthy  child,  with  the  exception  of 
an  attack  of  varicella  in  infancy,  until  twelve  months  before  admission. 
At  that  time  the  mother  had  begun  to  notice  that  the  child's  water  con- 
tained blood.  At  first  this  had  only  occurred  about  once  a  week  ;  but  the 
frequency  of  the  haemorrhage  had  gradually  increased,  and  dui'ing  the 
previous  fortnight  blood  had  been  passed  every  day.  The  morning  urine, 
passed  after  the  night's  rest,  had,  however,  been  always  uncoloured  until  a 
week  before  admission  ;  since  that  time  the  passage  of  blood  had  been 
continuous. 

At  first  the  mother  had  noticed  no  other  symptoms,  but  after  the 
hremorrhage  had  continued  for  several  months,  the  patient  had  begun  to 
complain  of  pain  in  the  left  side  and  back,  at  first  only  occasionally,  but 
latterly  several  times  in  the  day.  The  child  cried  bitterly,  and  attempted 
to  relieve  her  distress  by  bending  her  body  backwards  across  her  mother's 
knee,  with  her  head  and  legs  hanging  down. 

On  admission,  the  girl  was  in  good  condition  and  had  a  florid  com- 
plexion. Her  weight  was  twenty-two  pounds  ten  ounces.  Her  liver  and 
spleen  were  of  normal  size,  and  the  heart  and  lungs  were  healthy.  The 
abdomen  was  unusually  compressible.  The  aorta  and  iliac  arteries  could 
be  felt  pulsating  on  deep  pressure,  and  both  kidneys  could  be  felt.  They 
were  not  tender  when  touched,  and  seemed  in  every  way  normal.  She 
passed  water  more  frequently  than  was  natural,  but  there  was  no  pain  in 
micturition.  Her  skin  was  not  harsh,  acted  fairly  well,  and  there  was  no 
sign  of  oedema.  The  ui*ine  was  dark  with  blood,  of  specific  gravity  1.024, 
threw  down  a  copious  precipitate  on  boiling,  and  showed  an  abundance  of 
blood-corpuscles  under  the  microscope.  After  a  few  days  stellate  crystals 
of  uric  acid  were  also  discovered  in  the  sediment. 

The  child  was  kept  in  bed,  and  was  given  a  mixture  containing  carbo- 
nate of  potash.  The  amount  of  blood  in  the  water  gradually  decreased,  and 
in  five  days  had  quite  disappeared.  The  uiine  then  became  perfectly 
normal,  and  ceased  to  contain  albumen  or  blood-corpuscles.     There  were 


766  DISEASE  EST   CHILDEElSr. 

never  any  signs  of  casts,  of  purulent  matter,  or  of  mucus.  No  pain  Tvas 
noticed  during  her  residence  in  the  hospital,  and  she  Tvas  soon  dischai'ged. 
About  a  month  afterwards  she  was  readmitted  -^ith  the  same  symptoms, 
but  they  quickly  disappeared  as  before  with  rest  and  alkalies.  Her  tem- 
perature was  always  normal. 

This  case  is  a  good  illustration  of  the  symptoms  produced  in  children 
by  renal  concretions  in  the  kidney.  It  wordd  be  difficult  to  attribute  the 
ha?matuiia  to  any  other  cause.  The  signincant  fact  that  the  bleeding  oc- 
curred for  the  most  part  after  exercise,  and  that  until  the  amormt  of  blood 
became  excessive,  the  water  was  clear  in  the  moraing  when  the  child  first 
rose  from  her  bed,  were  strong  arguments  in  favora-  of  uiinaiy  concre- 
tions. The  patient,  besides,  was  in  good  condition,  and  of  a  healthy  ap- 
pearance, and  although  her  kidneys  could  be  felt  on  jDalpation,  no  increase 
in  their  size  could  be  detected.  Lastly,  crystals  of  uric  acid  were  found  in 
the  sediment. 

Examination  of  the  luine  in  these  cases  often  gives  a  negative  result. 
Calculus  may  exist  in  the  kidney  without  giving  rise  to  symptoms  of  any 
kind.  Between  the  attacks  of  haematuria  the  water  may  contain  neither 
blood  nor  albumen,  and  unless  sand  or  crystals  of  uric  acid  be  actually 
passing,  it  may  redden  htmus  paper  but  faintly. 

Sometimes  the  irritation  produced  by  the  presence  of  the  calculus  in 
the  pelvis  of  the  kidney  may  set  up  pyelitis.  The  stone  then  usually  be- 
comes enlarged  by  deposition  of  phosphatic  salts  upon  its  surface. 

A  child  Avas  admitted  into  the  East  London  Children's  Hospital,  suffer- 
ing from  tubercular-  meningitis.  After  death,  which  took  place  in  two  days' 
time,  besides  the  morbid  apjoearances  usual  in  such  cases,  the  left  kidney 
was  found  to  be  extensively  diseased.  The  organ  was  much  enlarged  and 
contained  about  two  ounces  of  creamy  pus.  Li  the  interior  it  was  hollowed 
into  cavities,  and  its  proper  substance  was  almost  replaced  by  caseous 
matter.  A  calculus  of  the  size  of  a  cherry-stone  was  impacted  in  the  upper 
part  of  the  ui-eter.  Above  this,  the  ui'eter  and  pelvis  of  the  kidney  were 
much  dilated.  In  this  case,  no  doubt,  the  stone  had  fii'st,  by  the  initation 
it  produced,  set  up  pyehtis,  and  had  then  become  impacted  in  the  ureter, 
preventing  the  escape  of  the  pui'ulent  matter. 

When  the  concretion  passes  from  the  kidney  into  the  ureter,  and  down- 
wards into  the  bladder,  there  is  always  pain  ;  but  the  child  suffers  far  less 
than  an  adult  would  do  under  similar  circumstances.  Sometimes  an  attack 
of  abdominal  pain  in  a  child,  attributed,  as  all  such  pain  is  apt  to  be,  to 
abdominal  derangement  and  colic,  is  followed  by  symptoms  of  stone  in  the 
bladder.  It  is  therefore  desu-able  in  all  cases  where  pain,  more  than  or- 
dinarily severe,  appears  to  be  suffered,  to  examine  the  state  of  the  child's 
water,  and  inquu-e  of  the  nurse  whether  sand  or  gTavel  has  been  seen  at 
the  bottom  of  the  chamber-pan. 

If  the  stone  becomes  impacted  in  the  ui'eter,  serious  consequences  may 
ensue.  The  uuitation  of  the  foreign  body  in  this  situation  may  set  up  in- 
flammation, and  give  rise  to  thickening  and  contraction  immediately  above 
the  seat  of  the  impediment.  Higher  up  the  ureter  becomes  greatly  dis- 
tended, and  the  pelvis  of  the  kidney  may  suffer  dilatation.  In  some  cases 
the  pressure  of  the  secreted  fluid,  accuniulating  in  the  channels  above  the 
obstruction,  may  flatten  out  the  kidney  into  a  thin-waUed  cyst.  This  is 
one  form  of  hydronephrosis. 

"WTien  the  stone  has  entered  the  bladder,  ui-gent  symptoms  begin  to  be 
noticed.  This  affliction  is  more  common  in  boys  than  in  guis  ;  probably 
for  purely  mechanical  reasons.     The  lu-ethra  in  girls  is  short,  straight, 


CALCULUS   OF   THE   KIDNEY — SYMPTOMS — DIAGNOSIS.        767 

and,  when  the  child  stands  upright,  ahnost  vertical.  In  boys  it  is  long 
and  sinuous  with  a  double  bend.  In  the  bladder  the  stone  produces  gi'eat 
irritation.  Priapism  is  common  ;  and  there  is  usually  pain,  which  is  in- 
creased by  exercise.  During  micturition  the  boy  cries  with  pain,  which  he 
refers  to  the  end  of  the  genital  organ,  and  endeavours  to  relieve  by  squeez- 
ing and  rubbing  the  part  with  his  fingers.  The  flow  of  urine  often  stops 
suddenly,  from  the  stone  being  carried  by  the  flow  of  water  into  the  neck 
of  the  bladder,  and  there  forming  an  impediment  to  the  escape  of  the 
urine.  Consequently  the  water  is  voided  with  effort,  and  the  straining- 
may  give  rise  to  prolapse  of  the  rectum.  Actual  retention  may  occur,  the 
stone  being  tightly  grasped  by  the  sphincter  vesicae,  and  impacted  at  the 
beginning  of  the  prostatic  urethra.  A  little  pure  bright  blood  may  be 
passed  at  the  end  of  micturition,  and  the  urine  often  gives  evidence  of  se- 
vere catarrh  of  the  bladder.  Any  of  these  symj)toms  occurring  in  a  boy 
shouM  make  us  inquire  very  carefully  into  the  cause  of  his  complaints. 
It  must  not,  however,  be  forgotten  that  very  similar  symptoms  may  arise 
from  different  reasons.  Dr.  West  has  pointed  out  that  in  cases  where  the 
prepuce  is  abnormally  long,  with  a  narrow  opening,  its  edges  may  become 
very  sore  on  account  of  the  difficulty  and  delay  with  which  urine  is  forced 
through  the  orifice  ;  and  this  may  give  rise  to  much  pain  in  micturition. 

Diagnosis. — ^On  account  of  the  frequency  with  which  uric  acid  concre- 
tions are  found  in  the  urine  of  children,  it  is  evident  that  the  delicate 
membrane  lining  the  tubules  of  the  kidney  is  liable  to  be  exposed  to  injury 
from  the  sharp  edges  of  the  crystalline  masses.  Consequently,  haemor- 
rhage in  such  cases  is  no  matter  for  surprise.  The  wonder,  indeed,  is  that 
it  is  not  a  more  common  symptom  of  uric  acid  sand  in  young  persons. 
That  it  is  not  so  is  probably  due  to  the  fact  that  the  uric  acid  is  commonly 
deposited  from  the  urine  in  the  bladder  itself,  and  not  at  a  higher  point  in 
,  the  urinary  apparatus.  Sir  Thomas  Watson  has  recorded  his  opinion  that 
many  of  the  obscure  cases  of  hsematuria  in  the  adult  may  be  referred  to 
renal  calculi.  In  the  case  of  children  it  may  be  laid  down  as  a  rule  that 
renal  hsemorrhage  occurring  in  a  child  otherwise  healthy,  and  accompanied 
by  no  symptoms,  nor  by  hsemorrhage  from  other  parts  of  the  body,  is,  in  the 
majority  of  cases,  to  be  attributed  to  the  irritation  of  crystalhne  masses  in 
the  tubules,  calices,  or  pelvis  of  the  kidney. 

Not  long  ago  I  saw  a  little  boy,  aged  ten  mouths,  who  for  six  weeks 
had  been  passing  water  mixed  largely  with  blood.  Sometimes  for  a  few 
days  together  the  water  would  be  clear,  but  the  hsematuria  speedily  re- 
turned. The  specimen  brought  with  the  child  was  bright  crimson  in  col- 
our, and  consisted  of  blood  and  urine  intimately  blended  together.  It  had 
a  slightly  acid  reaction.  Many  blood-corpuscles  were  seen  under  the  mi- 
croscope, bu  no  crystals  of  uric  acid  could  be  detected,  although  the  med- 
ical attendant  had  occasionally  found  them  in  the  sediment.  The  child 
had  been  brought  up  by  hand  and  fed  upon  cow's  milk  and  water.  He 
had  no  teeth,  could  not  stand,  and  showed  signs  of  being  under-nourished. 
The  bowels  were  confined  habitually ;  otherwise  he  seemed  to  suffer  no  dis- 
comfort, and  was  said  never  to  be  peevish  or  fretful. 

As  the  infant  was  evidently  insufficiently  fed,  I  rearranged  his  diet,  order- 
ing one  meal  in  the  morning  of  oatmeal  (one  teaspoonful)  with  cow's  milk, 
two  meals  of  Nestle's  milk  food,  and  two  or  three  meals  of  MeUin's  food 
with  cow's  milk  diluted  with  a  third  part  of  barley-water.  I  also  prescribed 
a  mixture  containing  the  infusions  of  senna  and  gentian,  so  as  to  act  gently 
upon  the  child's  bowels. 

Some  months  afterwards  I  heard  that  the  bleeding  had  continued  for  a 


768  DISEASE   IN   CHILDEEJS^. 

few  weeks  longer  ;  that  the  child  had  then  seemed  in  great  pain  for  a  day 
and  a  night  ;  but  that  after  this  the  water  had  become  clear,  and  had  ever 
since  been  perfectly  free  from  blood.  The  nutrition  ^had  begun  to  improve 
immediately  ujDon  the  change  of  diet. 

There  can  be  little  doubt  that  the  hgematuria  in  this  case  was  the  con- 
sequence of  ii'ritation  of  the  kidney  by  a  small  angular  concretion  ;  and 
the  pain  spoken  of  was,  in  all  probability,  an  attack  of  renal  colic,  caused 
by  the  passage,  or  attempted  passage,  of  the  httle  calculus  down  the  ure- 
ter. In  cases  such  as  this,  the  concretions  must  be  looked  for  carefully  in 
the  urine  passed  at  the  end  of  a  fit  of  cohc.  They  are  often  no  larger 
than  a  mustard-seed,  or  even  a  small  pin's  head. 

Prognosis. — The  occasional  ajDpearance  of  free  ui'ic  acid  in  the  mine  of 
infants  and  children  is  of  no  consequence  whatever.  The  frequent  passage 
of  sandy  particles  is  of  greater  moment,  for  in  these  cases  we  are  justified 
in  fearing  the  formation  of  a  stone  in  the  bladder.  A  mere  passing  hgema- 
turia should  not  have  too  much  importance  attached  to  it ;  for  it  is  prob- 
able that  a  certain  oozing  of  blood  may  occur  in  the  kidney,  as  a  con- 
sequence of  ii'ritation  ii'om  small  crystalline  fragments,  which  may  be 
afterwards  washed  away.  Repeated  haemorrhage  fi'om  this  source  is, 
however,  to  be  regarded  "with  anxiety  ;  and  if  there  are  signs  of  pain  in 
the  renal  region  preceding  or  accompanying  the  flow  of  blood,  we  have 
reason  to  fear  the  presence  of  a  calculus,  and  further  ill-consequences  are 
to  be  anticipated. 

Treatment. — The  frequent  appearance  of  uric  acid  crystals,  or  of  sandy 
dejjosits,  or  even  the  habitual  presence  of  ui-ates  in  a  child's  water,  should 
make  us  inquii-e  very  carefully  as  to  the  food  he  takes,  and  the  general 
conditions  under  which  he  is  hving.  Such  a  child  should  hve  plainly. 
He  should  take  meat  once  a  day  with  vegetables,  and  a  Mght  custard  or 
batter  pudding.  For  his  other  meals  he  should  have  milk  and  bread-and- 
butter,  with  occasionally  the  yolk  of  an  egg  or  a  little  bacon  for  his  break- 
fast. Care  should  be  taken  that  he  does  not  overload  his  stomach,  and 
the  quantity  of  farinaceous  food  he  eats  should  be  duly  proportioned  to 
his  power  of  digesting  it.  Sweet  things  should  be  given  to  the  child  with 
caution ;  and  all  cakes  and  biscuits  between  meals  should  be  strictly  for- 
bidden. He  should  take  exercise  freely  in  the  open  air.  His  skin  should 
be  kept  in  good  order  by  complete  washing  every  day,  and  in  the  colder 
months  he  should  be  dressed  from  head  to  foot  in  some  warm  woollen 
material.  Great  attention  should  be  paid  to  the  ventilation  of  his  bed- 
room, and  in  the  winter  he  should  be  dressed  and  undressed  in  a  well- 
warmed  room.  In  the  case  of  an  infant,  vigilance  should  be  exercised 
that  the  child  does  not  take  too  large  a  C[uantity  of  food  at  one  time,  and 
that  he  is  not  burdened  by  too  much  farinaceous  matter  to  his  meals. 
Cleanhness  and  jolenty  of  fresh  air  must  be  alwaj'S  insisted  upon. 

In  addition  to  the  above  measures,  care  should  be  taken  that  the  patient 
drinks  sufficient  fluid  to  freely  dilute  the  renal  secretion.  Remembering 
that  a  concentrated  state  of  the  lu'ine  is  alone  sufficient  to  give  lise  to 
sandy  deposits  in  the  urine,  the  child  should  be  made  to  drink  half  a  tum- 
bler of  water,  fasting,  one  hour  before  food,  twice  a  day.  This  simj)le 
precaution,  in  many  cases,  will  at  once  put  an  end  to  any  appearance  of 
sand.  An  infant  may  be  given  thin  barley-water  from  his  bottle  with  the 
same  object. 

For  medicine,  alkalies,  such  as  the  citrate  of  potash,  should  be  given, 
and  the  treatment  must  be  continued  for  several  weeks.  If  hsemorrhage 
occur,  perfect  rest  in  bed  must  be  enforced.     These  cases  seldom  requii-e 


CALCULUS   OF   THE   KIDNEY — TREATMENT.  769 

styptics,  but  if  thought  advisable,  a  few  grains  of  gallic  acid  may  be  given 
with  dilute  sulphuric  acid  twice  a  day. 

If,  from  attacks  of  pain  or  frequent  haemorrhages,  it  becomes  evident 
that  the  child  has  a  calculus  of  the  kidney,  citrate  of  potash  should  be 
given  in  sufficient  doses  to  keep  the  urine  shghtly  alkaline  ;  and  this 
treatment  should  be  persevered  with  in  the  hope  of  dissolving  the  concre- 
tion, or  at  any  rate  of  reducing  its  size  sufficiently  to  enable  it  to  escape 
by  the  ureter.  If  great  irritation  and  pain  are  produced  by  the  continued 
presence  of  the  calculus,  and  the  health  and  strength  of  the  child  seem  to 
be  seriously  affected,  the  question  of  nephrotomy  should  be  considered. 

In  an  attack  of  nephritic  colic,  the  child  should  be  kept  under  the  in- 
fluence of  morphia,  and  hot  fomentations  must  be  appHed  to  the  abdomen. 

49 


CHAPTEE  TV. 

TUMOURS   OF  THE  KIDNEY. 

Tumours  of  the  kidney  are  occasionally  seen  in  children,  and  generally 
occur  in  the  form  either  of  a  sarcomatous  growth  or  of  a  hydronephrosis. 

Sarcoma  of  the  kidney  constitutes  the  ordinary  form  of  renal  cancer 
met  with  in  the  child.  It  occurs  usually  at  an  early  age  (the  cases  which 
have  come  under  my  notice  have  been  all  under  three  years  old),  and  is 
usually  confined  to  one  side  of  the  body.  In  the  kidney,  as  in  other  or- 
gans, the  growth  often  reaches  a  very  large  size. 

Morbid  Anatomy. — The  sarcoma  is  usually  of  the  round-celled  variety; 
but  the  tumour  often  contains,  in  addition  to  sarcoma  tissue,  striated  mus- 
cular fibre  scattered  or  arranged  in  bundles.  Under  the  microscope  these 
tumours  are  found  to  have  a  fibrillated  structure,  some  fibres  being  slightly 
spindle-shaped,  with  an  indication  of  a  nucleus ;  others,  more  elongated, 
with  signs  of  transverse  striation  ;  others,  again,  well-developed,  with  dis- 
tinct striation.  But  even  in  the  best  developed  fibres  no  sign  of  a  sarco- 
lemma  can  be  seen.  In  some  cases  the  new  muscular  and  sarcomatous 
tissue  is  dispersed  through  the  kidney  substance,  and  the  tumour  is  then 
really  a  tumour  of  the  kidney.  In  other  cases  the  new  tissue  seems  to  be 
separated  from  the  kidney  substance  proper,  although  lying  within  the 
capsule  ;  or  it  divides  the  organ  into  two  parts  without,  as  in  the  other 
case,  infiltrating  its  substance.  It  has  been  suggested  that  these  growths 
may  be  derived  from  the  remains  of  the  Wolffian  body. 

Symptoms. — No  pain '  seems  to  attend  the  development  of  these  tu- 
mours, and  at  first  there  is  little  interference  with  the  general  health. 
Consequently,  the  earliest  sign  to  attract  the  attention  of  the  attendants  is 
the  unusual  size  of  the  child's  belly  ;  and  the  mother  often  complains  that 
the  belly  feels  harder  on  one  side  than  it  does  on  the  other. 

On  examination,  in  such  cases,  we  find  a  globular  swelhng  occupying 
one  side  of  the  abdomen.  The  swelling  is  usually  Httle  movable,  and 
does  not  descend,  or  moves  very  shghtly,  in  inspiration.  Its  borders  ^re 
rounded,  and  there  is  no  edge  felt,  as  is  the  case  with  the  spleen.  Its 
substance  is  soft  and  elastic,  so  as  to  convey  an  imperfect  sense  of  fluctua- 
tion. Below,  the  fingers  can  be  pressed  between  the  lower  border  and 
the  brim  of  the  pelvis  ;  above,  the  tumour  jDasses  beneath  the  liver,  or  on 
the  left  side  is  continuous  with  the  splenic  dulness  beneath  the  false  ribs  ; 
externally,  the  swelling  reaches  backwards  into  the  loin,  and  there  is 
seldom  any  intestinal-resonance  to  be  detected  between  it  and  the  spine. 

As  the  tumour  grows  the  only  inconvenience  felt  is  the  weight  of  the 
mass  in  the  abdomen.  The  appetite  is  good,  often  exceptionally  keen, 
and  nutrition  is  fairly  performed.  The  urine  is  usually  normal,  although 
in  some  cases  it  may  contain  albumen  and  blood  ;  and  towards  the  end  it 
may -be  scanty,  with  infrequent  mictiirition. 

After  a  time,  as  the  size  of  the  growth  increases,  secondary  derange- 


TUMOUES    OF   THE    KT.DNEY — SYMPTOMS.  771 

ments  from  pressiire  begin  to  be  noticed.  The  earliest  sign  that  the  growth 
is  interfering  with  neighbouring  parts  is  usually  an  enlargement  of  the  su- 
perficial veins  of  the  abdominal  wall  from  pressui'e  upon  the  vena  cava.  This 
is  often  followed  by  oedema  of  the  lower  limbs  and  scrotum.  Sometimes 
the  hver  enlarges  from  passive  congestion  ;  and  dyspnoea  may  be  induced 
from  pressure  upwards  of  the  diaphragm  by  the  renal  mass.  When  these 
signs  are  noticed  nutrition  becomes  aifected,  and  the  end  is  not  far  off. 
The  child  gets  thinner,  and  soon  wastes  rapidly.  His  appearance  becomes 
cachectic  ;  aphthse  develope  in  the  mouth,  and  he  sinks  and  dies.  Before 
death  the  emaciation  may  be  extreme. 

These  symptoms  are  well  illustrated  by  the  case  of  a  patient  in  the 
East  London  Children's  Hospital,  under  the  care  of  my  colleague,  Dr. 
Donkin,  through  whose  kindness  I  had  several  opportunities  of  examin- 
ing it. 

A  little  girl,  aged  two  and  a  half  years,  was  brought  to  the  hospital  on 
account  of  a  swelling  of  the  belly.  The  mother  stated  that  she  had  no- 
ticed three  months  before  that  the  belly  was  large  and  hard  on  one  side, 
and  that  a  doctor  had  said  there  was  a  tumour  of  the  abdomen.  For  a 
month  the  child  had  been  languid  and  fretful,  picking  her  nose,  and 
moaning  in  her  sleep.  Now  and  then  she  had  complained  of  abdominal 
pains,  and  once  or  twice  she  had  vomited.  The  bowels  were  disposed  to  be 
costive,  and  the  water  was  occasionally  milky  (from  lithates). 

The  child  was  full-grown  for  her  age  and  well-nourished.  She  did  not 
look  ill.  The  abdomen  was  large  and  full,  especially  on  th6  right  side, 
and  the  superficial  veins  were  distended.  On  palpation  of  the  belly  a 
large,  oval,  smooth  mass  was  felt  on  the  right  side,  reaching  from  the  liver 
to  the  level  of  the  brim  of  the  pelvis.  The  fingers  could  be  passed  un- 
der the  lower  border  of  the  tumour,  and  above  could  be  pushed  a  little 
way  between  the  upper  border  and  the  hver,  the  edge  of  which  could  be 
distinctly  felt  overlapping  the  upper  part  of  the  mass.  Anteriorly,  the 
swelling  reached  beyond  the  middle  line  of  the  beUy,  and  its  limits  could 
be  distinctly  felt  rounded  and  resisting.  Posteriorly,  the  tumour  passed 
backwards  into  the  renal  region,  and  its  boundaries  in  this  direction  could 
not  be  ascertained,  although  when  the  child  lay  on  her  left  side  the  reso- 
nance of  the  intestine  could  be  made  out  posteriorly.  In  front  the  colon 
could  be  detected  lying  on  the  surface  of  the  swelling. 

The  whole  tumour  was  very  slightly  movable  ;  its  surface  was  smooth ; 
its  substance  elastic,  and  it  felt  like  a  tense  bag  of  fluid.  There  was  no 
ascites  ;  no  enlarged  glands  could  be  felt  in  the  groins  or  elsewhere  ;  the 
edge  of  the  liver  reached  two  fingers'  breadth  below  the  ribs  ;  there  was 
no  enlargement  of  the  spleen.  In  oixler  positively  to  exclude  fluid,  an  ex- 
ploratory puncture  was  made  into  the  tumovu',  but  nothing  but  a  little  blood 
was  withdrawn.     The  temperature  remained  normal  after  the  puncture. 

For  a  fortnight  after  the  child's  admission  there  was  httle  change  in 
her  condition.  Then,  however,  her  temperature  rose  ;  she  vomited,  and 
began  to  look  ill  and  careworn,  and  a  pneumonia  developed  in  the  base 
of  the  right  lung.  The  urine  became  intensely  acid ;  it  was  loaded  with 
urates,  and  deposited  large  amounts  of  uric  acid  on  standing ;  there  was 
also  a  trace  of  albumen.  The  liver  enlarged  ;  the  veins  of  the  abdominal 
waU  became  engorged  with  blood ;  oedema  occurred  in  the  lower  limbs ; 
the  face  got  dusky ;  general  convulsions  came  on,  with  epistaxis  and  bleed- 
ing from  the  ears,  and  the  child  died  in  a  few  minutes. 

On  examination  of  the  body  a  round-celled  sarcomatous  tumour,  the 
size  of  a  foetal  head,  was  seen  occupying  the  lower  two-thirds  of  the  right 


772  DISEASE   liS"   CHILDKEN. 

kidney,  infiltrating  its  tissue.  It  was  covered  by  the  renal  capsule.  Its 
substance  was  of  soft  pulpy  consistence  in  the  centre,  harder  and  firmer 
towaixls  the  circumference.  There  was  one  large  haemorrhage  into  its  lower 
part.  The  tumoiu*  pressed  upon  the  inferior  vena  cava,  which  was  dis- 
tended by  a  large  decolourised  thrombus,  perforated  in  the  middle  by  a 
channel  of  the  diameter  of  a  goose-quill.  The  thrombus  reached  fi'om  the 
level  of  the  tumour  upwards  to  the  right  ventricle  of  the  heart.  The  hver 
and  spleen  were  both  much  congested. 

This  case  may  be  considered  a  typical  example  of  a  renal  tumour.  The 
only  doubt  possible  was  as  to  the  nature  of  the  swelling,  and  this  the 
exploratory  puncture  removed  at  once.  Fluid  being  thus  excluded,  the 
rarity  of  any  other  form  of  solid  growth  made  the  diagnosis  of  sarcoma 
comparatively  an  easy  one. 

Sarcomatous  tumours  of  the  kidney  generally  gi'ow  rapidly,  and  the 
course  of  the  disease  is  seldom  protracted.  Death  often  occui's  within  a 
year  of  the  swelling  being  first  discovered,  and  in  the  longest  case  life  is 
rarely  prolonged  beyond  eighteen  months. 

Hydronephrods  is  almost  invariably  in  children  a  congenital  affection. 
It  is  often  associated  with  some  form  of  aiTest  of  development,  such  as  club- 
foot, harelijD,  imperforate  anus,  or  absence  of  the  prostate  gland.  Both  kid- 
neys are  more  often  affected  than  one  alone,  and  the  most  common  cause  is 
impervious  ureters  or  an  imperforate  urethra.  According  to  Dr.  Englisch, 
the  obstruction  may  take  its  rise  in  the  vahnilar  folds,  situated  at  the  upper 
part  of  the  ureter,  or  at  its  lower  part  ;  and  in  five  cases  he  refeiTed  the 
cause  of  the  obstruction  to  a  curring  of  the  mucous  membrane  at  the  orifice 
of  the  urethra  into  a  diverticulum. 

In  rare  cases  the  disease  is  acquii'ed  duiing  childhood  from  impaction 
of  a  calculus  in  the  ureter.  The  other  causes  of  acquired  hydi-onephi'osis, 
viz.,  retroflexion  and  prolapse  of  the  womb,  etc.,  do  not  come  into  play 
until  a  more  advanced  period  of  life. 

"VMiatever  be  the  cause  of  the  retention,  the  essence  of  the  disease  con- 
sists in  accumulation  of  urine  in  the  pelvis  of  the  kidney.  The  pressui-e 
of  this  fluid  produces  very  serious  consequences.  Every  degree  of  dilata- 
tion of  the  parts  is  seen  according  as  to  whether  the  fluid  can  partially  es- 
cape or  is  wholly  retained.  In  every  case  the  renal  pelvis  is  greatly 
dilated,  but  there  are  many  degrees  of  alteration  of  the  kidney  substance, 
from  mere  flattening  and  toughening  of  the  papillae  to  actual  conversion 
of  the  organ  into  a  membranous  sac  filled  with  fluid.  If  the  obstruction 
is  low  down  in  the  ureter,  this  tube  is  also  dilated  and  its  wall  thickened. 
The  fluid  has  a  low  specific  gravity,  and  contains  the  elements  of  urine  al- 
though in  feeble  proportion  ;  i.e.,  urea,  uric  acid,  urates,  and  often  crystals 
of  oxalate  of  lime.  Its  reaction  is  faintly  alkahne.  Its  coloiu'  is  clear  amber 
or  turbid,  and  may  be  yellow  from  pus  or  reddish  from  blood.  Some- 
times it  contains  epithelium,  and  in  rare  cases  the  consistence  is  increased 
to  a  thick  fatty  fluid. 

Symptoms. — Although  almost  invariably  congenital,  the  hydronephi'osis 
is  often  not  noticed  until  several  months  or  even  years  have  elapsed  from 
birth.  The  mother  then  observes  that  the  abdomen  is  enlarged,  and  that 
the  chief  swelling  is  limited  to  one  side  of  the  beUy.  Her  attention  being 
thus  directed  to  the  child's  abdomen  she  finds  that  this  progressively  in- 
creases in  size,  and  a  medical  practitioner  is  consulted. 

The  tumour  is  a  painless  one  and  forms  a  soft  elastic  swelling  in  the 
situation  of  the  kidney.  The  cyst  sometimes  reaches  a  large  size,  and 
may  cause  great  inconvenience  by  its  weight,  or  interfere  with  respiration 


TUMOURS   OF   THE  KIDJS'EY — SYMPTOMS — DIAGl^OSIS.         773 

lay  pressing  upwards  against  the  diaphragm.  The  lumbar  region  on  the 
aifected  side  is  then  seen  to  be  prominent  as  the  chUd  lies  on  his  face,  and 
fluctuation  is  transmitted  freely  from  the  front  to  the  back.  In  a  case  re- 
corded by  Dr.  Hilliex- — a  child  three  years  and  a  half  old — the  swelling 
filled  the  whole  abdomen,  and  five  pints  of  clear  non-albuminous  fluid 
were  withdrawn  by  tapping.  Sometimes  an  escape  of  some  of  the  retained 
fluid  occurs  from  time  to  time,  and  the  size  of  the  tumour  may  thus  undergo 
marked  variations.  If  the  accumulation  be  due  to  an  impacted  calculus, 
attacks  of  nephritic  colic  may  occur,  with  bloody  urine.  If  both  kidneys 
are  affected,  and  the  escape  of  fluid  is  entirely  prevented,  the  child  may 
die  with  symptoms  of  uraemia.  Such  a  condition  is  of  course  incompat- 
ible with  life,  and  if  it  be  a  congenital  one,  the  child  is  generally  stillborn. 

Diagnosis  of  Renal  Tumours. — We  have  first  to  satisfy  ourselves  that 
the  tumour  is  due  to  enlargement  of  the  kidney,  and  then  to  ascertain  the 
nature  of  the  swelling.  In  order  to  arrive  at  an  accurate  diagnosis,  a 
careful  examination  of  the  abdomen  is  of  course  indispensable  ;  so  that  if 
the  child  is  fretful  and  unmanageable,  crjang  and  contracting  his  abdom- 
inal walls,  he  should  be  jDut  under  the  influence  of  an  anaesthetic. 

A  rounded  mass  in  which  no  edge  can  be  detected,  situated  in  the 
region  of  the  kidney,  and  little  afliected  by  respiration ;  one  which  does 
not  dip  into  the  pelvis,  but  passes  upwards  to  the  liver  or  spleen  and 
backwards  into  the  lumbar  region — such  a  tvimour  is  in  all  probability  an 
enlarged  kidney.  Renal  tumours  may  be  confounded  with  tujnours  of  any 
■other  abdominal  organ,  or  indeed  with  a  swelling  anywhere  within  the 
abdominal  cavity. 

On  the  right  side  the  renal  enlargement  must  be  distinguished  from  a 
tumour  of  the  liver.  The  latter  rises  and  faUs  with  respiration,  and  will  be 
noticed  to  lie  close  up  under  the  ribs  so  that  the  fingers  cannot  be  passed 
between  its  upper  border  and  the  diaphragm.  Moreover,  a  hepatic  tumour 
is  rarely  covered  by  a  coil  of  intestine  ;  and  on  careful  manipulation  the 
edge  can  usually  be  detected.  This,  of  course,  at  once  excludes  the  kidney, 
for  a  kidney,  whether  enlarged  or  not,  is  rounded  in  all  directions. 

On  the  left  side  a  splenic  tumour  must  be  excluded.  Enlargements  of 
the  spleen  are  very  common  in  children,  but  they  can  never  be  mistaken 
for  a  kidney  by  a  careful  observer.  An  enlarged  spleen  lies  very  super- 
ficially ;  its  position  is  markedly  influenced  by  respiration  ;  it  is  freely 
movable  ;  it  has  a  distinct  edge  towards  the  middle  line,  in  which  the  notch 
<3an  usually  be  felt,  and  its  upper  border  passes  upwards  beneath  the  ribs. 

On  either  side  the  renal  tumour  maybe  mistaken  for  a  mass  of  enlarged 
glands,  a  psoas  abscess,  faecal  accumulations,  and,  in  girls,  ovarian  enlarge- 
ments. 

Enlarged  glands  lie  very  deeply  against  the  spine,  and  have  to  be  felt 
for  with  care.  They  are  only  slightly  movable.  Still,  palpation  alone  may 
be  insufficient  to  distinguish  a  swelling  of  this  kind  from  an  enlarged 
kidney.  By  attention,  however,  to  the  general  symptoms,  we  may  usually'- 
arrive  at  a  conclusion.  A  kidney  only  slightly  enlarged  from  sarcoma  pro- 
duces no  impairment  of  the  general  health  ;  while  caseous  glands,  sufli- 
ciently  large  to  be  detectable  by  the  touch,  are  associated  with  a  history 
of  iU-health  or  of  more  or  less  interference  with  nutrition.  The  patient 
has  usually  suffered  from  attacks  of  diarrhoea,  and  may  perhaps  have  signs 
of  chronic  ulceration  of  the  bowels.  In  such  a  case  he  would  look  ih  even 
although  the  bowels  were  not  actually  loose. 

A  psoas  abscess,  like  a  renal  tumour,  occupies  the  region  of  the  loins 
and  extends  forwards  into  the  belly.     It  is,  however,  placed  more  deeply 


774  DISEASE   IN   CHILDREIsr. 

than  a  tumour  of  the  kidney,  and  cannot  be  so  easily  felt.  Little  informa- 
tion is  to  be  derived  from  the  presence  of  fluctuation  in  the  swelling  ;  for 
this  is  difficult  to  ascertain  in  a  psoas  abscess,  and  a  sarcomatous  kidney 
conveys  a  sense  of  pseudo-fluctuation  which  is  often  very  deceptive.  A 
far  more  important  distinction  is  that  fui'nished  by  the  actual  position  of 
the  mass,  for  a  renal  tumour  reaches  far  higher  in  the  abdomen  than  an 
abscess.  Moreover,  the  latter  is  distinctly  tender  on  pressure,  while  the 
kidney  tumour  is  quite  painless.  Lastly,  in  psoas  abscess,  although  there 
may  be  no  curvature  of  the  spine,  careful  examination  will  often  discover 
the  existence  of  disease  of  the  vertebrae  (see  page  185). 

Other  abscesses  in  the  neighbourhood  of  the  kidney  can  usually  be  de- 
tected by  their  causing  enlargement  behind  in  the  renal  region.  Accord- 
ing to  Sir  William  Jenner,  this  is  rarely  the  case  with  a  simple  swelhng  of 
the  kidney. 

Fsecal  accumulation  may  be,  perhaps,  mistaken  for  a  renal  tumour,- 
but  a  mass  sufficiently  large  to  give  rise  to  hesitation  must  be  very  rare  in 
the  child.  Faecal  lumps  lie  very  superficially,  and  can  be  indented  with 
the  finger.     Besides,  they  can  be  cleared  away  by  a  copious  injection. 

Ovarian  tumours  are  sometimes  found  in  httle  girls.  These  dijD  down 
into  the  pelvis,  and  the  fingers  cannot  be  passed  beneath  their  lower  bor- 
der. Moreover,  they  are  rarely  covered  by  coils  of  intestine.  These  are 
all  pressed  away  towards  the  lateral  regions  of  the  groin. 

Having  ascertained  the  existence  of  a  renal  tumour,  it  is  sometimes 
very  difficult  to  decide  upon  its  natui"e.  If  the  tumour  be  doiible,  or  be 
accompanied  by  signs  of  severe  nej)hritic  colic,  it  is  probably  due  to  a 
hydronephrosis.  So,  also,  if  the  swelling  is  noticed  to  be  diminished  in 
size  after  a  copious  flow  of  urine,  it  may  be  attributed  to  the  same  condi- 
tion. Usually  the  doubt  can  be  only  removed  bj'  an  exj)loratory  puncture 
of  the  swelling.  If  fluid  be  withdrawn  containing  ui'ea,  there  can  be  no 
further  hesitation  as  to  the  nature  of  the  tumour. 

The  distinction  between  hydronephrosis  and  ascites  is  described  in  the 
chapter  treating  of  the  latter  disease  (see  page  703). 

Treatmient. — In  cases  of  sarcoma  of  the  kidney  we  can  do  nothing  but 
attend  to  the  general  nutrition  of  the  patient.  In  the  case  of  hydrone- 
phrosis : — If  occasional  reductions  in  the  size  of  the  tumoiu'  have  been 
noticed  to  follow  a  cojDious  discharge  of  urine,  friction  and  shampooing  of 
the  abdomen,  such  as  proved  successful  in  a  case  reported  by  Dr.  W. 
Roberts,  may  be  made  use  of.  In  other  cases  occasional  tapping  may 
greatly  relieve  the  patient.  Dr.  Day  reports  a  case  in  which  nephrectomy 
was  successfully  performed  by  Mr.  Knowsley  Thornton,  and  the  child  re- 
covered. A  cure  may,  however,  be  effected  by  a  less  serious  operation. 
It  appears  fi'om  a  case  recorded  by  Dr.  Tuckwell,  and  IMi'.  H.  P.  Symonds, 
of  Oxford,  that  persistent  drainage  of  the  sac  may  sometimes  lead  to  its. 
shrinking  and  contraction.  In  the  case  referred  to — a  bo}"  eleven  years  of 
age — an  incision  was  made  into  the  sac  in  the  lumbar  region,  and  a  large 
drainage-tube  was  introduced  through  the  opening.  Antiseptic  dressings- 
were  employed,  and  at  the  end  of  thirteen  Aveeks  from  the  operation  the 
tube  was  finally  removed.  The  child  recovered  perfectly,  and  six  months 
afterwards  no  sign  of  the  tumour  could  be  discovered  on  examination  of 
the  belly.  Operative  interference  in  these  cases  should  not  be  undertaken 
unless  a  healthy  state  of  the  mine  indicates  that  the  opposite  kidney  is 
free  from  disease. 


CHAPTER  V. 

VULVITIS. 

Vulvitis,  or  vulvo-vaginitis  (for  the  catarrhal  inflammation  of  the  mucous 
membrane  often  penetrates  for  some  distance  into  the  vaginal  canal),  is 
very  common  in  little  girls.  The  complaint  may  be  seen  at  a  very  early 
age,  even  during  the  first  few  months  of  Hfe  ;  but  is  more  common  in 
children  of  five  years  of  age  and  upwards.  M.  Parrot  has  described  a 
variety  of  the  derangement  which  he  calls  "  aphthous  vulvitis,"  and  states 
that  it  is  met  with  most  frequently  in  children  between  the  second  and 
fourth  year. 

Causation. — Catarrhal  vulvitis  is  especially  common  in  children  of 
scrofulous  constitution,  and  appears  to  be  excited  by  want  of  cleanHness 
and  insanitary  conditions  generally  ;  also  by  local  irritation  in  the  neigh- 
bourhood, as  by  ascarides  in  the  rectum.  In  very  rare  cases  it  may  be  the 
consequence  of  sexual  violence.  Certain  forms  of  the  complaint  appear  to 
be  contagious  and  capable  of  being  communicated  from  one  child  to  an- 
other by  sponges  or  towels ;  and  Dr.  Atkinson,  of  Baltimore,  has  stated 
his  behef  that  the  discharges  from  a  purulent  ophthalmia  may  be  conveyed 
to  the  vulva,  and  set  uj)  a  similar  inflammation  in  that  situation. 

Vulvitis  is  sometimes  a  secondary  disease.  Thus,  it  may  come  on  after 
some  of  the  acute  specific  diseases.  Parrot  has  seen  aphthous  vulvitis 
succeed  most  commonly  to  measles,  next  to  whooping-cough.  He  has  also 
met  with  it  after  varicella,  erysipelas,  pneumonia,  and  diphtheria.  In 
only  a  few  cases  Avas  it  apparently  a  pi-imary  derangement. 

Symptoms. — In  catarrhal  vulvitis  a  purulent  discharge  may  be  noticed 
to  issue  from  the  vulva.  At  first  it  is  scanty,  and  is  seen  on  the  child's 
body  linen.  On  inspection  of  the  parts  the  mucous  membrane  is  found  to 
be  red,  and  the  larger  labia  to  be  a  httle  swollen.  The  discharge  is  yel- 
lowish or  greenish  in  colour.  It  is  usually  fetid,  and  in  many  cases  is 
very  profuse.  In  hospital  out-patients,  who  are  often  neglected  in  the 
matter  of  cleanHness,  the  opening  of  the  vagina  is  often  found  bathed  with 
a  thickish,  yellow,  offensive  matter.  If  the  catan-h  is  not  quickly  cured,  it 
may  lead  to  considerable  swelling  of  the  labia,  and  the  mucous  membrane 
may  become  excoriated.  In  these  cases  there  may  be  some  pain  in  walk- 
ing ;  and  if  the  catarrh  extends  to  the  orifice  of  the  lU'etlu'a,  there  may  be 
smarting  in  micturition.  There  is  not  usually  any  enlargement  of  the  in- 
guinal glands  ;  but  in  bad  cases,  occiu-ring  in  unhealth}',  neglected  chil- 
dren, irritable  sores  may  form  on  the  inner  sui'face  of  the  labia,  and  the 
glands  may  then  become  shghtly  swollen,  and  a  little  tender.  I  have 
never  seen  suppuration  of  these  glands.  If  left  untreated,  spontaneous 
recovery  may  take  place,  or  the  discharge  may  become  chronic,  and  per- 
sist for  months  or  even  years.  The  swelling  in  these  cases  subsides,  but 
thin  purulent  matter,  small  in  quantity,  continues  to  be  secreted.     I  have 


776  DISEASE   IN    CHILDREN. 

thought,  iu  some  of  these  chroBic  cases,  that  irritation  has  been  kept  up 
by  a  habit  of  masturbation. 

Aphthous  vulvitis,  according  to  Parrot,  attacks  the  labia  majora,  and 
sometimes  the  smaller  Hps  and  the  clitoris.  From  these  parts  the  aphthous 
inflammation  may  spread  to  the  genito-crural  folds,  the  groins,  the  peri- 
nseum,  and  the  borders  of  the  anus.  It  begins  by  an  eruption  of  small, 
rounded,  or  semi-spheroidal  elevations  of  the  epidermis,  of  a  grayish- white 
colour,  and  often  depressed  in  the  centre.  The  little  patches  closely  re- 
semble the  aphthous  spots  on  the  buccal  mucous  membrane,  and  are  sur- 
rounded by  a  red,  slightly-swoUen  ring.  In  number  they  are  five  or  six 
to  fifteen,  and  may  be  placed  singly  or  iu  groups  ;  sometimes  they  are 
confluent.  After  a  period  varying  from  thirty-six  hours  to  three  days,  the 
patches  give  place  to  ulcers  which  have  a  gray  or  yellowish  base,  and  a  red 
border.  They  catise  considerable  irritation,  which  it  is  difficult  to  prevent 
the  patient  from  reUeving  by  the  use  of  the  fingers.  At  the  height  of  _  the 
disease  the  edges  of  the  sores  are  raised,  and  the  parts  aroimd,  especially 
the  minor  labia  and  the  clitoris,  are  swollen  and  bright  red.  Under  suita- 
ble treatment  the  swelling  soon  subsides,  and  the  ulcers  heal ;  but  in  un- 
healthy subjects  the  lesion  may  take  on  a  gangTenous  process.  When  this 
occurs  the  constitutional  symptoms  are  severe,  and  the  gangrene  may 
spread  extensively,  and  present  aU  the  features  described  elsewhere  (see 
Gangi-ene  of  the  Vulva,  page  170). 

Diagnosis.— Vulvitis  is  a  very  common  derangement  amongst- the  chil- 
dren of  the  poor,  but  may  be  found  in  any  condition  of  life.  Knowing 
its  frequency,  we  must  be  on  our  guard  against  accejDting  any  suggestion 
(such  as  some  mothers  are  very  ready  to  make)  that  their  child  has  been 
tampered  with  by  a  person  of  the  opposite  sex.  If  this  have  really  taken 
place,  we  should  expect  to  find  ecchymosis  and  recent  abrasions  of  the 
external  genitals.  The  hymen  is  rarely  ruptured,  on  account  of  the  small- 
ness  of  the  passage. 

The  aphthous  spots  are  distinguished  from  mucous  patches  by  the  ab- 
sence of  aU  signs  of  constitutional  symptoms  in  the  child.  The  ulcers  are 
distinguished  from  venereal  sores  by  the  absence  of  any  hardening  at  the 
base.  Moreover,  the  latter  are  never  grouped  or  confluent,  as  is  almost 
invariably  the  case  with  the  aphthous  ulcers. 

Treatment.— The  utmost  cleanliness  must  be  observed.  The  parts 
should  be  bathed  frequently  or  syringed  with  warm  water,  and  afterwards 
a  little  pledget  of  cotton-wool,  soaked  in  a  mild  lead  lotion,  should  be 
passed  between  the  labia.  If  the  catarrhal  inflammation  seem  to  have  ex- 
tended into  the  vagina,  the  lotion  may  be  injected  with  a  syringe.  If 
there  be  great  irritation  of  the  parts,  a  weak  solution  of  perchloride  of 
mercury  (one  grain  to  eight  ounces  of  water)  may  be  used  instead  of 'the 
lead.  If  the  case  be  obstinate,  the  parts  should  be  well  dabbed  with 
a  weak  solution  of  nitrate  of  silver  (gT.  vj.-x.  to  the  ounce  of  distilled 
water). 

Dr.  GaiUard  Thomas  recommends  for  aU  obstinate  cases  the  careful 
syringing  of  the  vagina  with  warm  watei',  and  the  use  afterwards  of  a  lotion 
composed  of  one  ounce  of  black  wash  to  the  pint  of  water.  The  lotion 
must  be  injected  with  a  syringe  twice  a  day,  and  on  each  occasion  the  pas- 
sage must  be  previously  cleansed  by  careful  injection  of  warm  water.  Dr. 
Thomas  attributes  the  chronic  course  of  many  of  these  cases  to  the  imperfect 
apphcation  of  remedies.  He  urges  the  importance  of  instructing  the  mother 
in  the  use  of  the  syringe,  directing  her  to  introduce  the  nozzle  of  the  instru- 
ment well  into  the  vagina,  so  that  the  upper  part  of  the  passage  is  reached 


VULVITIS — TEEATMENT.  777 

by  the  fluid.  In  all  instances  where  the  child  is  anaemic  or  of  scrofulous 
aspect,  iron  wine  and  cod-liver  oil  should  be  given  internally.  Care  must 
also  be  taken  that  the  bowels  are  regularly  relieved,  and  that  objectionable 
habits  are  no  longer  continued. 

In  the  aphthous  form  of  vulvitis,  Parrot  recommends  the  use  of  the 
powder  of  iodoform  once  a  day  thoroughly  after  careful  washing.  He 
then  apjolies  a  covering  of  lint.  Parrot  states  that  this  application  quickly 
cures  the  sores,  and  prevents  the  occurrence  of  gangrene. 


art  12. 
DISEASES  OF  THE  SKIN. 


CHAPTER  I.     . 

DISEASES  OF  THE  SKIN. 


In  childhood  the  skin  shares  the  general  susceptibility  of  the  whole  sys- 
tem, and  is  very  liable  to  disease.  At  this  period  of  life  the  surface  of 
the  body  is  delicate  and  readily  irritated  by  the  presence  of  accumulated 
dirt  and  dried  secretion.  Amongst  the  poor,  neglect  and  want  of  cleanH- 
ness  are  common  causes  of  cutaneous  affections  in  the  young.  Moreover, 
in  the  young  subject,  gastro-intestinal  derangements  are  especially  hable 
to  be  accompanied  by  the  various  forms  of  erythema ;  and  childhood  ap- 
pears in  itself  to  increase  the  susceptibihty  to  the  parasitic  diseases  of  the 
skin.  In  a  work  treating  of  disease  in  early  Hfe,  a  consideration  of  the 
various  eruptions  to  which  childhood  is  liable  must  not  be  entirely  neg- 
lected ;  but  attention  will  be  confined  to  the  more  common  forms  of  skia 
disease  met  with  at  this  period  of  life,  and  the  subject  must  necessarily  be 
discussed  somewhat  cursorily,  and  chiefly  with  a  view  to  diagnosis  and 
treatment. 

The  papular  eruptions  do  not  require  very  extended  notice.  Lichen  is 
very  rare  in  the  young  subject.  The  form  called  lichen-  urticatus  is  the 
most  common  ;  but  this  eruption  appears  to  be  more  a  modification  of  net- 
tle rash  than  a  true  Hchen,  and  will  be  afterwards  referred  to  under  the 
head  of  urticaria. 

Prurigo  is  occasionally  met  with  in  dirty,  neglected  children  in  the 
form  of  slightly  projecting  papules,  which  give  rise  to  considerable  irrita- 
tion ;  but  in  early  life  the  rash  seems  to  induce  a  less  intense  form  of  itch- 
ing than  that  which  is  a  cause  of  so  much  suffering  to  older  persons.  Mr. 
Hutchinson  has  described  a  prurigo  of  infants  which  appears  often  to  be 
a  sequel  to  or  modification  of  chicken-pox  ;  and  he  is  disposed  to  believe 
that  an  abortive  varicella  is  often  the  original  cause  of  the  outbreak.  The 
papules  are  hard  and  rough,  and  may  be  mixed  up  with  wheals  of  urticaria. 
In  some  cases  they  are  large,  and  resemble  half-developed  wheals  of  nettle' 
rash,  "with  perhaps  even  some  tendency  to  vesication."  The  itching  aris- 
ing from  the  eruption  is  often  greatly  relieved  by  the  use  of  warm  baths, 
medicated  with  the  liq.  carbonis  detergens,  in  the  proportion  of  two  tea- 
spoonfuls  to  the  gallon  of  water.  This  bath  should  be  used  tmce  a  day. 
The  skin  may  be  afterwards  anointed  with  a  salve  composed  of  one  ounce 


DISEASES    OF   THE   SKIN— STEOPHXTLUS — PEMPHIGUS.        779 

of  storax,  two  drachms  of  white  wax,  and  half  an  ounce  of  olive-oil.  If  the 
child  is  feeble  or  delicate,  cod-liver  oil  and  iron  wine  should  be  prescribed, 
and  the  diet  should  be  regulated  on  the  principles  elsewhere  recommended 
(see  Infantile  Atrophy). 

Strophulus  is  a  common  eruption  in  infants,  and  usually  arises  as  a  con- 
sequence of  laboured  digestion.  It  is  met  with  in  two  principal  forms — a 
red  and  a  white  variety.  Bed  strophulus  consists  of  small  red  papules  of 
the  size  of  a  large  pin's  head.  These  papules  often  occur  in  groups,  and 
occupy  the  face,  the  trunk,  and  sometimes  the  limbs.  They  cause  some 
itching.  In  white  strophulus  the  colour  of  the  papules  is  pearly  white. 
Each  papule  lasts  a  few  days,  and  the  rash  usually  comes  out  in  successive 
crops.  It  is  not  accompanied  by  any  general  symptoms,  and  the  only 
treatment  required  is  attention  to  the  digestive  organs,  and  some  necessary 
modification  in  the  diet. 

Of  the  vesicular  and  bullous  group,  heipes  and  pemphigus  are  both  far 
fi'om  rare.  Herpes  of  the  lip  is  as  common  a  symptom  of  croupous  pneu- 
monia in  the  child  as  it  is  in  the  adult.  Herpes  of  the  pharynx  is  de- 
scribed elsewhere  (see  page  580).  Herpes  zona  is  comparatively  rare  in 
the  child,  but  is  sometimes  seen,  and  then  differs  little  from  the  same 
eruption  in  the  adult  except  that  it  is  much  less  frequently  followed  by 
intercostal  neuralgia.     It  requires  no  treatment. 

Pemphigus  is  occasionally  met  with  in  the  child.  In  new-born  infants 
a  syphilitic  form  of  the  disease  is  not  uncommon,  and  usually  indicates 
profound  contamination  of  the  system.  Syphilitic  pemphigus  is  referred 
to  elsewhere. 

Pemphigus  attacks  iU-nourished  children,  and  may  be  found  to  occur 
during  convalescence  from  acute  febrile  diseases  such  as  scarlatina.  It  is 
also  apt  to  be  met  with  as  a  frequently  recurring  complaint  in  children  of 
fairly  robust  appearance,  and  in  such  cases  it  is  difficult  to  know  what  is 
the  cause  of  the  repeated  returns  of  the  bullous  eruption.  In  the  more 
common  variety  of  the  disease  the  eruption  begins  in  the  form  of  smaU 
red  spots.  On  these  spots  the  cuticle  rises  raj^idly  into  a  bleb,  which  in- 
creases in  size  until  it  is  as  large  as  a  marble  or  a  walnut.  The  bladders 
thus  formed  are  tense,  and  filled  with  fluid,  and  their  base  is  surrounded 
with  a  red  zone  of  inflammation.  The  fluid  is  at  first  clear,  but  soon  be- 
comes opaque.  The  blebs  may  last  unbroken  for  some  days,  but  usually 
they  burst  very  early,  and  give  place  to  thin  yellowish  brown  scabs  on  a 
purplish  ground.  The  eruption  comes  out  in  successive  crops.  Many 
blebs  do  not  appear  at  one  time,  but  the  repeated  succession  of  crops 
covers  the  body  with  bladders,  crusts,  and  stains  from  the  various  stages 
of  the  affection-  being  simultaneously  present  on  the  skin.  All  parts  of 
the  body  may  be  affected,  even  the  Hps  and  the  ears,  but  the  palms  and 
soles  usually  escape.  The  appearance  of  the  eruption  is  accompanied  by 
some  constitutional  disturbance,  which  is  often  found  to  vary  in  severity 
according  to  the  extent  of  surface  involved  in  the  disease.  There  may  be 
some  fever.  In  a  boy  aged  eight  years,  who  was  admitted  into  the  East 
London  Children's  Hospital  with  extensive  pemphigus,  the  temperature 
during  the  first  tlnree  days  was  over  101°  both  morning  and  evening,  and 
for  a  fortnight  afterwards  it  rose  sometimes  in  the  evening  to  99.8°  or  100°. 
Thirst,  restlessness,  and  loss  of  appetite  are  also  noticed,  and  there  is  some- 
times diarrhoea.  The  eruption  at  first  may  be  accompanied  by  some 
itching,  but  after  the  bursting  of  the  blebs  the  resulting  sores  cause  pain 
and  smarting. 

An  occasional  form  of  the  disease  is  that  called  pemphigus  solitarvus, 


780  DISEASE   IZS"   CHILDEE]S". 

where  a  single  bleb  rises  on  the  hand  or  foot,  often  on  one  finger,  and 
quickly  attains  a  great  size.  Sometimes  the  bleb  involves  the  whole  of 
the  hand.  Mr.  Naylor  described  a  variety  of  pemphigus  which  he  called 
"  povvpholyx  diutinus  in  children."  This  form  begins  Hke  ordinary  pem- 
phigus as  a  small  red  spot,  which  becomes  a  bleb  and  rapidly  enlarges. 
After  the  bladder  has  ruptured  the  sore  still  continues  to  spread,  and  be- 
comes covered  with  a  thin  wrinkled  crust  with  a  narrow  raised  rim,  the 
remains  of  the  bleb.  The  disease  ajDpears  to  be  a  purely  local  one,  and  the 
general  health  is  quite  unaffected.  Dr.  E.  Liveing  has  doubts  if  this  af- 
fection be  a  true  j)emphigus. 

The  sore  of  pemphigus,  like  other  sores,  may  assume  a  gangrenous 
form  in  unhealthy,  cachectic  childi'en.  The  resulting  condition  is  veiy 
much  that  abeady  described  as  a  consequence  of  gangrenous  varicella  (see 
joage  49). 

The  duration  of  the  disease  is  apt  to  be  prolonged,  and  sometimes  the 
eniption  returns  very  rapidly  after  apparent  cure.  The  nature  of  the 
affection  can  hardly  be  mistaken,  for  the  large  blebs  or  bhsters  surrounded 
by  healthy  skin  are  pathognomonic.  Blebs  are  often  seen  in  the  coiu'se  of 
other  forms  of  skin  disease,  such  as  scabies,  eczema,  erysipelas,  etc.  In  the 
latter  malady  the  extensive  reddened,  brawny  siu'face  on  which  the  bladder 
is  seated  will  be  a  sufficient  distinction.  In  the  case  of  the  two  former 
complaints  the  characteristic  appearances  pecuHar  to  these  disorders  will 
be  observed.  The  bullous  syphiloderm  is  distinguished  from  pemphigus 
by  the  presence  of  other  signs  of  the  constitutional  disease.  In  infants 
bullous  eruptions  are  commonly  of  syphilitic  origin. 

The  best  treatment  for  pemphigus  is  arsenic.  The  remedy  should  be 
given  in  full  doses,  for  a  child  of  six  years  and  upwards  will  take  doses  as 
large  as  those  usually  prescribed  for  an  adult.  If  the  irritation  and  dis- 
comfort of  the  skin  and  general  nervous  disturbance  prevent  sleep,  opium 
is  useful,  more  especiall}^  as  in  the  ojjinion  of  experienced  observers  the 
drug  has  a  direct  curative  influence  upon  the  disease.  It  is  especially 
ser\dceable  in  the  early  acute  stage.  The  sores  on  the  skin  must  be  kept 
very  clean  and  treated  with  some  mild  apphcation,  such  as  a  lead  lotion  or 
zinc  ointment. 

Ecthymatous  ijustuleH  are  very  common  in  early  life.  In  children  of  all 
ages,  irritation  of  the  skin  is  very  apt  to  be  followed  by  the  development 
of  large  flattened  pustules  seated  on  a  broad  base  and  sruTounded  by  a 
red  zone  of  inflammation.  Their  favourite  seats  are  the  face,  hands,  and 
feet.  The  subjects  of  the  complaint  are  often  under-noui'ished,  and  it  is 
therefore  very  often  seen  amongst  the  children  of  the  poor  ;  but  in  all  ranks 
of  hfe  any  derangement  or  other  cause  which  determines  a  temporary  re- 
duction of  strength  appears  to  have  a  predisposing  influence  in  inducing 
the  eruption.  Such  children  are  usually  pale  and  flabby,  and  in  them 
any  shght  scratch  may  be  followed  by  a  festering  sore  which  continues 
unhealed  as  long  as  the  debihty  from  which  the  patient  is  suffering  re- 
mains unreheved.  Quinine  has  a  specific  influence  in  removing  this 
troublesome  affection.  After  the  alkaloid  has  been  taken  for  a  few  days  or 
a  week  the  jDustules  disappear,  the  sores  heal,  and  the  child  is  weU.  In 
all  these  cases  the  diet  should  be  attended  to  and  any  error  of  feeding 
coiTected.  A  little  wine  is  often  of  seiwice,  and  the  child  should  have 
plenty  of  fresh  air  and  exercise. 

A.  mild  form  of  -psoriasis  is  met  with  in  children.  The  eruption  usually 
occurs  in  the  form  of  psoriasis  guttata,  the  little  patches  being  scattered 
about,  not  very  thickl}',  on  the  trunk  and  limbs.     The  patches  ai'e  usually 


DISEASES    OF   THE   SKITT — PSORIASIS — PARASITIC.  781 

small,  of  a  pale  red  tint,  and  are  more  or  less  scaly  on  the  surface.  They 
may  be  attended  with  slight  itching.  Psoriasis  is  seldom  obstinate  at  this 
period  of  life,  and  usually  yields  without  difficulty  to  arsenical  treatment. 
Sometimes,  however,  the  perchloride  of  mercuiy  seems  to  be  more  useful 
than  arsenic.  As  a  local  application  the  unguentum  picis,  or  a  mild 
chrysophanic  acid  ointment  (gr.  x.  to  the  ounce  of  lardj,  may  be  made 
use  of. 

The  parasitic  diseases  of  the  skin  will  be  described  afterwards.  In  the 
present  chapter  reference  may  be  made  to  the  form  of  disease  called 
alopecia  areata,  which  is  not  unfrequently  seen  on  the  heads  of  children  of 
five  years  of  age  and  upwards.  The  disease  is  characterised  by  the  loss  of 
hair  in  spots  on  the  scalp.  At  these  spots  the  hair-bulbs  atrophy,  and  the 
hairs,  growing  loose,  are  shed  without  undergoing  any  other  alteration  in 
structure.  In  this  way  bald  patches  are  formed,  in  which  the  scalp  is 
completely  smooth,  white,  and  hairless.  At  the  circumference  of  the 
patch  the  hair  grows  thickly  as  on  the  unaffected  parts  of  the  head.  The 
number  of  patches  may  be  one  or  more,  and  they  may  spread  so  as  to  unite 
and  almost  denude  the  head  of  its  hair.  At  one  time  the  disease  was 
thought  to  be  parasitic,  but  it  is  now  allowed  by  most  pathologists  to  be  a 
simple  atrophy  of  the  hair-bulb  ;  and  the  hairs  examined  microscopically 
are  found  to  resemble  in  every  respect  those  which  are  cast  oft'  in  the 
natural  process  of  decay. 

The  disease  usually  tends  to  spontaneous  cure.  The  bald  patches 
become  eventually  covered  with  a  fine  down  which  grows  thicker  and 
darker  until  at  last  the  spot  ceases  to  be  recognised.  In  some  cases  the 
new  hairs  remain  colourless  and  give  a  curiously  variegated  appearance  to 
the  head.  In  others  the  hair  is  only  partially  reproduced,  so  that  in  places 
the  scalp  may  remain  permanently  bald. 

The  only  treatment  for  this  condition  is  energetic  stimulation  with 
irritating  applications,  such  as  tincture  of  iodine,  cantharides,  etc.  Dr. 
Thin  recommends  sulphur  ointment. 

The  above  varieties  of  cutaneous  eruption  may  be  dismissed  without 
further  notice.  There  are,  however,  other  forms  of  skin  disease  which 
from  their  frequency  or  importance  require  a  more'  detailed  description. 
The  following  chapters  will  therefore  be  devoted  to  the  consideration  of 
the  erythemata,  eczema,  molluscvma  contagiosum,  the  parasitic  diseases,  and 
sclerema. 


CHAPTER  II. 

THE   ERYTHEMATA. 

In  tlie  erythematous  group  of  skin  affections  the  rash  presents  itself  in  the 
form  of  slightly  raised  patches  of  redness.  These  patches  are  of  variable 
size  and  shape,  give  rise  to  little  or  no  constitutional  disturbance,  and  run 
a  very  rapid  course.  In  all  cases  the  redness  shows  a  smooth  surface, 
without  scales,  and  disappears  on  pressure,  returning  when  the  pressure  is 
removed. 

The  varieties  which  will  be  described  are  : — Erythema  simplex  and  its 
varieties  ;  erythema  nodosum  ;  urticaria,  and  roseola. 

ERYTHEMA  SIMPLEX. 

The  simple  variety  of  erythema  appears  to  be  in  many  cases  the  con- 
sequence of  digestive  disturbance.  The  rash  is  seen  in  the  form  of  patches, 
often  of  some  considerable  size.  The  colour  is  red,  bright  or  inclining  to 
be  dusky  ;  and  the  affected  part  is  in  most  cases  sensibly  elevated  from 
exudation  of  serum  and  leucocytes  into  the  cutis  and  subcutaneous  tissue. 
The  duration  of  the  rash  is  variable.  In  the  commonest  form,  which  is 
called  erythema  fugax,  absorption  of  the  exuded  matter  takes  place  very 
rapidly,  and  in  the  course  of  a  few  hours  the  redness  has  completely  dis- 
appeared. This  form  is  common  in  the  face  of  a  child  who  is  fed  in- 
judiciously, and  suffers  in  consequence  from  fermentation  and  acidity. 
The  patches  are  of  very  irregular  shape  and  are  imperfectly  circumscribed. 
They  are  often  accompanied  by  some  irritation  or  a  sense  of  tingling. 
There  is  little  swelling  of  the  skin  ;  indeed,  the  affection  appears  to  be 
little  more  than  a  cutaneous  hypersemia.  When  the  erythema  occurs  in 
small  raised  blotches  it  is  called  erijthema  papulatum.  The  rash  then  con- 
sists of  flattened  red  spots  of  the  size  of  a  large  pin's  head  or  a  pea.  Their 
margin  is  well  defined  and  they  are  accompanied  by  some  little  irritation. 
A  common  seat  of  the  eruption  is  the  extremities,  and  it  is  rare  on  the 
trunk  and  face.  The  rash  lasts  a  few  days,  then  begins  to  fade,  and  as- 
sumes a  bluish  tint  before  it  finally  disappears.  If  there  has  been  much 
swelling  a  slight  desquamation  is  left  on  the  skin. 

A  common  form  of  erythema  in  infants  is  that  known  as  erythema  in- 
tertrigo. In  this  variety  the  redness  appears  between  the  folds  of  skin  in 
fat  babies,  and  seems  to  be  due  to  the  friction  of  adjacent  surfaces  upon 
one  another.  It  is  seen  in  the  neck,  armpits,  groins,  and  inner  parts  of 
the  thighs.  If  the  redness  does  not  quickly  disappear  the  surface  becomes 
moist  and  slightly  excoriated.  It  is  then  often  called  eczema  intertrigo. 
In  severe  cases  linear  ulcerations  may  be  seen  to  occupy  the  bottom  of  the 
folds.  In  this  stage  the  disorder  can  no  longer  be  considered  as  a  mere 
erythema.     The  ulcers  have  sharp,  inflamed  edges,  and  pour  out  a  sero- 


THE   ERTTHEMATA — EEYTHEMA   SIMPLEX   AND   NODOSUM.     783 

purulent  fluid  in  considerable  quantities.  A  variety  of  erythema  int^trigo 
is  the  superficial  dermatitis  which  is  common  in  children  who  suffer  from 
diarrhoea.  The  irritation  of  the  discharges  fi'om  the  bowel  produces  a 
more  or  less  extensive  erythema  of  the  buttocks  and  perinseum,  which, 
however,  quickly  disappears  under  treatment. 

There  is  one  other  form  of  erythema  which  requires  mention,  viz.,  that 
which  is  produced  by  the  action  of  belladonna  upon  the  system.  This 
form  of  erythema  resembles  very  closely  the  rash  of  scarlatina.  In  some 
children  it  is  induced  very  readily,  and  is  not  to  be  taken  as  an  index  of 
the  susceptibility  of  the  system  to  the  action  of  the  drug.  The  readiness 
with  which  it  is  produced  seems  to  depend  more  upon  the  sensitiveness  of 
the  skin  than  upon  any  intolerance  of  the  drug  special  to  the  individual 
child.  As  a  rule,  young  subjects  can  take  large  quantities  of  belladonna 
without  inconvenience ;  and  in  some  cases  we  find  the  characteristic  rash 
developed  in  a  child  in  whom  much  larger  doses  are  required  to  produce 
any  dilatation  of  the  pupil. 

Diagnosis. — These  varieties  of  erythema  simplex  can  scarcely  be  mis- 
taken for  any  more  serious  disease.  If  the  patches  are  of  some  size,  they 
are  distinguished  from  erysipelas  by  the  want  of  sharp  outline,  the  lighter 
colour  of  the  redness,  the  absence  of  any  brawny  sensation  to  the  finger, 
the  normal  temperature,  and  the  entire  absence  of  constitutional  disturb- 
ance. Erythema  papulatum  may  perhaps  be  sometimes  confounded  with 
measles,  but  it  is  distinguished  by  the  larger  size  of  the  blotches,  the  want 
of  crescentic  arrangement,  the  limitation  of  the  rash  to  the  extremities, 
and  the  absence  of  catarrhal  symptoms  and  fever. 

Treatment. — In  ordinary  erythema  little  treatment  is  required.  Any 
digestive  disturbance  must  be  remedied,  and  it  is  well  to  act  upon  the 
bowels  with  a  moderate  dose  of  rhubarb  and  soda.  If  the  rash  persists 
after  twenty-four  hours,  a  mild  diaphoretic  may  be  administered,  such  as 
liq.  ammonise  acetatis  with  spirits  of  chloroform,  diluted  with  water. 

Tn  erythema  intertrigo  the  part  should  be  bathed  with  warm  water  and 
carefully  dried.  Afterwards,  a  piece  of  lint  wetted  with  unboiled  white  of 
egQ,  or  a  weak  lead  lotion,  should  be  inserted  between  the  folds  of  skin  and 
the  affection  is  quickly  at  an  end.  If  there  is  constipation,  a  mild  aperient 
— castor-oil,  or  rhubarb  and  soda — should  be  administered.  If  ulceration 
have  occurred,  the  part  should  be  washed  frequently  so  as  to  prevent  ac- 
cumulation of  secretion,  and  the  same  application  should  be  made  use  of. 
The  erythema,  which  is  excited  by  the  irritation  of  faecal  discharges,  quickly 
yields  to  frequent  bathing  with  warm  water,  careful  drying,  and  dusting 
with  lycopodium,  or  with  a  powder  composed  of  oxide  of  zinc  diluted  with 
three  times  its  weight  of  starch. 


ERYTHEMA  NODOSUM. 

Although  erythema  nodosum  is  usually  included  amongst  the  varieties 
of  erythema,  it  is  right  to  say  that  the  affection  is  looked  upon  by  some 
observers  as  a  specific  illness  which  ought  properly  to  be  classed  with  en- 
teric fever  and  the  other  varieties  of  acute  specific  disease.  By  others  the 
complaint  is  supposed  to  have  a  distinct  connection  with  the  rheumatic 
constitution,  and  there  is  no  doubt  that  it  often  attacks  the  subjects  of 
rheumatism. 

The  appearance  of  the  rash  is  often  preceded  by  pains  in  the  limbs 
and  lassitude.     The  spots  themselves  are  large  oval  patches  or  swelhngs 


784  DISEASE   i:!T   CHILDEEI^. 

of  a  rosy  red  tint,  and  measure  from  one  to  three  or  four  inches  in  their 
long  diameter.  They  usually  occupy  the  front  of  the  legs  and  are  accom- 
panied by  some  tenderness.  At  first  they  are  hard,  but  after  a  day  or  two 
become  softer,  and  may  even  give  a  sensation  of  semi-fluctuation  to  the 
finger.  At  the  same  time  the  coloui'  grows  more  and  more  pui-ple  until 
it  finally  disappears,  leaving  a  yellow  discoloui-ation  of  the  skin.  The 
patches  are  almost  always  present  on  both  legs,  and  sometimes  attack  the 
forearms  as  well,  or  even  other  parts  of  the  body.  Their  number  is  usually 
eight  or  ten. 

Each  swelling  goes  thi'ough  the  changes  characteristic  of  a  bruise, 
always  turning  fii'st  pui'ple,  then  yellow,  and  lasts  for  two  or  three  weeks. 
The  dui'ation  of  the  complaint  is,  however,  often  much  longer ;  and  con- 
valescence may  be  considerably  delayed  by  the  appearance  of  successive 
crops  of  the  nodose  j^atches. 

A  little  girl,  aged  twelve  years,  was  a  patient  in  the  East  London  Chil- 
dren's Hospital.  The  gui  had  been  suffering  for  nine  weeks  from  succes- 
sive crops  of  large  red  blotches  which  occupied  the  forearms  and  legs. 
There  were  also  a  few  on  the  belly.  They  began  as  small  red  spots,  which 
gTew  larger  and  became  elevated  and  swollen.  Their  colour  afterwards 
became  purple  and  they  then  faded  away  like  a  bruise.  The  child  was 
said  to  have  had  a  similar  attack  two  years  before.  She  had  complained 
for  a  forinight  of  pains  in  the  joints,  and  her  knee  had  been  swollen  for  a 
week  or  ten  days. 

While  the  patient  remained  in  the  hospital  various  joints  were  in  turn 
swollen  and  painful.  After  the  knee  had  recovered  the  right  wrist  became 
affected,  and  later  the  articulation  of  the  jaw  on  the  right  side  was  painful 
Afterwards,  the  pain  and  swelling  returned  to  the  wrist.  There  were  no 
signs  of  cardiac  mischief  ;  and  the  temperature  was  always  normal  in  the 
morning,  rising  at  night  to  between  99°  and  100°.  She  was  said  never  to 
have  had  rheumatic  fever.     Her  urine  was  normal. 

The  child  took  iodide  of  potassium,  quinine  and  u'on  without  benefit, 
but  improved  directly  the  treatment  was  changed  to  drachm  doses  of  oil 
of  turpentine.  Under  this  remedy  she  quickly  recovered  her  health.  The 
medicine  produced  little  aperient  action  on  the  bowels. 

According  to  M.  Germain  See,  erythema  nodosum  is  apt  to  be  compH- 
cated  by  disorders  of  the  respiratory  apparatus,  especially  pleurisy  and 
broncho-pneumonia. 

Diagnosis. — Erythema  nodosum  cannot  be  mistaken  for  any  other  form 
of  eruption.  The  large  oval  soft  swellings  seated  upon  the  front  of  the 
legs,  their  tenderness  on  pressure,  and  the  successive  changes  of  colour, 
such  as  is  characteristic  of  a  biniise,  which  the  swellings  undergo  in  their 
progress  to  recovery,  can  leave  little  doubt  as  to  the  natui-e  of  the  com- 
plaint. In  purpura  bruise-like  patches  are  often  seen,  but  the  spots  are 
much  smaller,  are  not  elevated,  are  accompanied  by  no  tenderness,  and 
are  not  altered  in  colour-  by  pressure  of  the  finger.  Moreover,  that  dis- 
ease is  often  accompanied  by  haemorrhages,  which  are  never  seen  in  un- 
complicated erj^hema  nodosum  ;  and  the  large  bmise-like  patches  on  the 
skin  are  mixed  up  mth  small  deep-red  petechise.  It  must  be  remem- 
bered, however,  that  the  two  diseases  may  occur  together,  for  erythema 
nodosum  is  an  occasional  comphcation  of  purpura. 

Treatment— The  patient  should  be  kept  in  bed  and  be  treated  with 
quinine  ;  and  the  bowels  shotdd  be  kept  regular  with  mild  aperients.  No 
local  treatment  is  required  unless  the  tenderness  of  the  patches  and  the 
pains  in  the  limbs  form  a  subject  of  complaint.     In  that  case  the  Hmbs 


THE  EEYTHEMATA — URTICAEIA.  785 

may  be  wrapped  in  cotton- wool.  In  tlie  more  chronic  cases  where  succes- 
sive crops  of  swellings  appear,  oil  of  tiu'pentine  may  be  given,  as  in  the 
case  narrated  above,  in  doses  of  one  or  two  drachms  three  times  a  day. 
The  child  may  have  meat  once  a  day,  but  no  potatoes  or  sweets  should  be 
allowed  while  the  pains  continue  troublesome. 


URTICARIA. 

In  urticaria,  or  nettle-rash,  the  erythematous  eruption  appears  in  the 
form  of  wheals  which  produce  the  most  distressing  irritation.  The  com- 
plaint may  be  acute  or  chronic,  and  sometimes  continues  with  varying  in- 
tensity for  months  or  even  years.  In  the  acute  form,  nettle-rash  is  a  com- 
mon consequence  of  indigestion  and  acidity,  and  is  often  excited  by 
special  articles  of  food,  such  as  shell-fish,  mushrooms,  etc.  Insanitary 
conditions  have  been  said  to  have  an  influence  in  promoting  the  disorder. 
Whether  this  be  so  or  not,  the  affection  is  no  doubt  common  in  neglected 
children  amongst  the  poor.  In  such  cases  it  may,  however,  be  the  conse- 
quence of  imcleanhness,  for  in  subjects  with  dehcate  skins  external  inita- 
tion  alone  will  set  up  the  complaint.  Thus,  the  eruption  may  be  produced 
by  pedicuh,  and  is  a  not  uncommon  complication  of  scabies  and  eczema. 
In  the  chronic  variety  nettle-rash  appears  to  be  in  many  cases  a  disorder 
of  purely  neiwous  origin  ;  for  the  eruption  is  often  quite  uninfluenced  by 
modifications  of  diet,  while  it  yields  readily  to  large  doses  of  quinine,  as 
wiU  be  afterwards  described. 

Symptoms. — In  its  common  form  the  rash  consists  of  a  number  of 
small  elevations  which  rapidly  increase  in  size  and  become  white  in  the 
centre  with  a  red  border.  These  wheals  are  of  various  sizes  and  shapes. 
The  smaller  may  be  of  the  diameter  of  a  pea ;  but  the  larger  may  measui-e 
one  or  two  inches  in  breadth  and  reach  a  considerable  elevation  above  the 
surface.  Sometimes  the  spots  assume  an  elongated  form  like  thick 
streaks ;  or,  again,  may  appear  as  a  bright  red  more  or  less  diffused 
ers'thematous  blush.  In  any  case  they  give  rise  to  a  stinging  ii'ritation 
which  necessitates  repeated  frictions  for  its  rehef.  The  itching,  however, 
is  increased  by  the  means  used  to  reheve  it,  and  the  act  of  rubbing  and 
scratching  the  skin  produces  a  fresh  crop  of  spots.  The  coui-se  of  each 
indiridual  wheal  is  very  short,  for  the  spots  come  and  go  with  gi'eat  rapid- 
ity. Any  part  of  the  body  may  be  affected.  The  wheals  may  appear  on 
the  face,  the  hands  and  feet,  the  limbs,  and  the  trunk  ;  and  the  rash  is. 
usually  roughly  symmetrical.  Sometimes  the  eruption  is  not  limited  tO' 
the  skin  but  affects  the  mucous  membrane  as  well.  Thus,  the  tongue  or 
throat  may  suddenly  swell  up  and  produce  alarming  symptoms ;  but  the 
swelling  subsides  again  as  rapidly  as  it  arose. 

In  acute  urticaria  there  may  be  weU-marked  constitutional  symptoms. 
The  rash  maybe  preceded  by  fever,  a  fui'red  tongue,  vomiting,  a  quick, 
feeble  pulse,  and  in  some  cases  a  distressing  feeling  of  prostration.  These 
symptoms  are  greatly  relieved  when  the  wheals  appear.  An  acute  attack 
of  nettle-rash  lasts  from  a  few  houi'S  to  several  days.  Even  in  this  short 
time,  it  varies  much  in  intensity,  and  is  usually  greatly  aggravated  at 
night. 

In  the  chronic  form,  the  disorder  continues  for  months.     Its  course  is 

always  very  variable,  and  is  subject  to   occasional  remissions,  so  that  it. 

more  resembles  a  series  of  acute  or  sub-acute  attacks.     In  this  form  the 

eruption  may  be  confined  to  certain  locahties  (urticaiia  conferia),  or  may 

50 


786  DISEASE   IN   CHILDKElSi. 

be  general  and  affect  all  parts  of  tlie  body  indiscriminately.  The  wheals 
are  sometimes  mixed  up  with  small  jDapular  projections,  and  the  complaint 
is  then  called  lichen  urticatus.  Another  variety  of  the  chronic  comjDlaint 
is  that  called  by  Dr.  Sangster  urticaria  pigmentosa.  The  wheals  are  here 
very  persistent,  and  leave  yellowish  pigmented  spots  on  the  skin. 

Diagnosis. — Urticaria  is  readily  recognised.  The  characteristic  wheals 
resembling  exactly  the  sting  of  a  nettle,  the  irritation  to  which  they  give 
rise,  and  the  rapidity  with  which  they  come  and  go,  leave  no  room  for  hesi- 
tation. The  severe  constitutional  symptoms  which  sometimes  precede  the 
acute  attack  might  conceivably  arise  from  so  many  causes  that  no  opinion 
should  be  hazarded  until  the  eruption  appears  and  explains  what  was  ob- 
scure. The  beginning  of  the  exanthemata  may  be  marked  by  similar 
phenomena,  and  the  metastasis  of  mumps  to  the  testicle  or  breast  is  occa- 
sionally preceded  by  like  symptoms. 

Treatment. — In  acute  nettle-rash  it  is  imjDortant  to  attend  to  the  condi- 
tion of  the  digestive  organs.  If  there  be  any  nausea,  a  mild  emetic,  such 
as  a  dose  of  ipecacuanha  wine,  should  be  administered  ;  and  the  child 
should  live  plainly  for  a  day  or  two,  without  sweets  or  excess  of  starches 
in  his  diet.  For  medicine,  an  aperient  dose  of  rhubarb  and  soda  will  usu- 
ally put  a  speedy  end  to  the  attack.  The  itching,  while  the  eruption  con- 
tinues, will  be  greatly  reheved  by  dabbing  the  surface  with  a  solution  of 
cyanide  of  potassium  (one  drachm  to  the  pint),  or  with  the  lotion  referred 
to  by  Sii'  Thomas  Watson,  composed  of  a  drachm  of  carbonate  of  ammonia 
and  the  same  quantity  of  acetate  of  lead  dissolved  in  eight  ounces  of  water. 
A  warm  bath  at  bedtime  in  some  cases  is  found  very  soothing. 

In  chronic  urticaria  excess  of  fermentable  food  is  to  be  avoided ;  but 
the  most  careful  dieting  will  often  produce  no  beneficial  effect  upon  the 
eruption.  In  the  majority  of  cases,  whatever  be  the  cause  of  the  persist- 
ence of  the  disorder,  it  will  be  found  to  yield  readily  to  full  doses  of  qui- 
nine. I  have  used  this  remedy  for  many  years,  and  have  not  yet  met  with 
an  instance  of  its  failure  to  put  an  immediate  end  to  the  complaint.  The 
dose  should  be  large,  and  may  be  roughly  calculated  at  one  grain  and  a 
half  for  each  year  of  the  child's  age.  The  remedy  is  administered  once  in 
the  day,  at  bedtime.  As  an  illustration  of  the  prompt  action  of  the  alka- 
loid so  administered,  I  may  quote  the  case  of  a  little  girl,  two  years  and 
ten  months  old,  who  had  suffered  fi'om  chronic  urticaria  for  two  years. 
The  rash  had  varied  in  intensity  from  time  to  time,  but  had  never  disap- 
peared entirely  ;  and  the  child  w^as  said  to  be  in  a  state  of  constant  suffer- 
ing from  the  distressing  itching  to  which  it  gave  rise.  A  fcAV  powders, 
each  containing  three  grains  of  quinine,  were  ordered  ;  one  to  be  taken 
every  night  on  going  to  bed.  After  two  or  three  powders  the  rash  -com- 
pletely disappeared,  and  two  years  afterwards  I  heard  that  it  had  never 
returned. 

ROSEOLA. 

Roseola,  or  the  rose  rash,  is  a  form  of  erythema  which  is  often  seen  in 
early  hfe,  and  although  a  very  trifling  complaint,  is  yet  on  account  of  the 
resemblance  it  bears  to  m^easles  of  some  chnical  importance. 

The  rash  is  especially  common  in  the  spring  and  the  autumn,  and  this 
partiality  to  certain  seasons  of  the  year  has  given  rise  to  the  names  of 
roseola  eestiva  and  roseola  autumnalis.  Like  the  other  forms  of  erythema 
the  complaint  is  not  contagious.  It  is  common  for  one  child  of  a  family 
to  be  the  only  one  attacked,  although  mixing  freely  with  the  others,  and 


THE    ERYTIIEMATA— EOSEOLA.  787 

•exposed  to  exactly  the  same  conditions.  The  rash  may  occur  several  times 
in  the  same  individual,  for  it  is  in  no  way  self-protective  ;  indeed,  the  con- 
trary seems  to  be  the  case,  and  its  tendency  rather  is  to  recur. 

The  causes  of  the  complaint  apjDear  to  be  digestive  derangement  and 
slight  chills.  The  eruption  occasionally  complicates  other  diseases.  Thus, 
it  may  come  on  in  the  pre-eruptive  stage  of  small-pox,  and  is  apt  to  occur 
in  vaccinated  children,  and  in  rheumatic  subjects. 

Symptoms. — The  appearance  of  the  rash  is  usually  preceded  by  slight 
«igns  of  disturbance.  The  child's  eyes  look  heavy,  his  appetite  is  poor, 
his  tong-ue  is  furred,  and  sometimes  he  vomits.  In  rarer  eases  the  bowels 
are  slightly  loose.  It  is  said  that  at  this  time  there  may  be  slight  eleva- 
tion of  temperature.  The  pre-eruptive  stage  lasts  usually  for  a  few  hours. 
The  rash  then  appears  as  bright  rose  spots,  which  come  out  very  rapidly, 
.and  soon  cover  large  surfaces  of  the  body.  The  size  of  these  spots  is  very 
much  that  of  the  eruption  of  measles  ;  and  sometimes,  as  in  that  disease, 
they  assume  a  crescentic  arrangement,  so  that  except  for  the  much  brighter 
colour  of  the  rash  the  general  appearance  of  the  child  is  that  of  one  suf- 
fering from  measles.  There  are,  however,  no  catarrhal  symptoms  of  any 
moment ;  the  throat  is  seldom  reddened,  and  there  is  no  cough. 

The  rash  lasts  a  few  hours  or  a  day  or  two,  and  then  subsides.  Usually, 
if  it  has  appeared  quickly,  it  fades  with  some  suddenness  ;  but  if  it  has  come 
out  slowly,  spreading  gradually  over  the  body,  it  disapjaears  in  an  equally 
leisurely  manner.  Sometimes  the  eruption  apjDcars  in  the  form  of  small 
circular  spots  which  remain  isolated  or  joined  irregularly  ;  and  in  some 
cases  the  rash  bears  a  close  resemblance  to  that  form  of  scarlatina  in  which 
the  spots  remain  discrete,  so  as  to  be  separated  by  skin  of  healthy  colour- 
ing. During  the  eruptive  stage  the  temperature  rarely  rises  above  the 
normal  level. 

A  little  girl  of  eight  years  old,  the  only  daughter  of  very  careful  parents, 
was  said  to  have  been  perfectly  well  without  any  sign  of  catarrh  or  other 
disturbance  until  noon  on  March  18th.  It  was  then  noticed  that  her  eyes 
were  heavy,  but  she  ate  her  dinner  as  usual.  In  putting  the  child  to  bed 
in  the  evening  it  was  found  that  she  had  some  red  spots  on  the  shoulder. 
During  the  night  she  sneezed  once  or  twice.  On  the  morning  of  the  fol- 
lowing day  the  face  and  body  were  covered  with  a  crescentic  rash  which 
bore  a  close  resemblance  to  the  eruption  of  measles.  It  differed  only  in 
colour,  for  the  tint  was  peculiarly  bright  and  rosy.  On  the  cheeks  the 
rash  was  confluent,  and  it  was  rather  papular  on  the  jaws.  There  was 
very  slight  injection  of  the  conjunctivae,  but  the  fauces  were  not  reddened. 
The  child  did  not  cough  or  snuffle,  and  there  was  no  rhonchus  or  other 
abnormal  sign  about  the  lungs.  A  painless,  movable  gland,  the  size  of  a 
filbert,  was  felt  just  below  the  occiput.  The  bowels  were  not  i-elaxed. 
There  was  no  special  thirst  or  loss  of  appetite.  The  temperature  at  2  p.m. 
was  99'^.     Pulse,  100. 

The  next  day  (March  20th)  the  rash  was  fading  fast.  The  temperature 
was  normal.     No  catarrhal  symptoms. 

Sometimes  the  roseolous  eruption  comes  and  goes  with  great  rapidity, 
lasting  only  a  few  hours.  In  such  cases  it  usually  readily  recurs.  The 
spots  sometimes  group  themselves  in  rings.  This  arrangement  is  held  to 
•constitute  a  special  variety — rotieola  annulata. 

Diagnosis. — Roseola,  when  it  assumes  the  crescentic  form,  is  distin- 
guished from  measles  by  the  absence  of  lengthened  prodromata  ;  by  the 
colour  of  the  rash  which,  instead  of  being  yellowish-red  or  dull  red,  is  of 
a,  bright  rose  tint ;  by  the  normal  or  only  moderately  elevated  temperature, 


788  DISEASE   IN   CHILDRElSr. 

and  by  the  absence  of  cough  and  coryza.  These  points  are  well  illustrated 
by  the  case  above  narrated.  It  is  more  difficult  to  distinguish  the  com- 
plaint from  rutheln  ;  for  in  both  disorders  the  eruption  appears  early  with 
only  shgh^  prodromata,  and  the  temperatiire  soon  becomes  normaL  In 
rotheln,  however,  there  is  a  sensible  elevation  of  the  temperature  during 
the  first  day  or  two  ;  the  soreness  of  throat,  which  is  almost  absent  in  rose- 
ola, is  a  marked  feature,  and  the  eruption  is  dull  red  with  none  of  the 
bright  rosy  tint  of  the  roseolous  rash.  Still,  in  spite  of  these  differences 
the  resemblance  between  the  two  complaints  is  sufficiently  close  to  make  it 
probable  that  rbseola  is  often  called  rotheln,  and  that  the  patient  is  sup- 
posed to  have  had  an  attack  of  "German  measles." 

The  diagnosis  between  roseola  and  scarlatina  is  given  elsewhere  (see 
page  42). 

Treatment. — The  treatment  required  for  roseola  consists  in  keeping 
the  child  quiet,  and  attending  to  any  digestive  derangement  which  may  be 
present.     Usually  no  medicine  is  necessary. 


CHAPTER  III. 

ECZEMA. 

Eczema,  one  of  the  commonest  of  skin  diseases  in  early  life,  and  often  one 
of  the  most  obstinate,  is  characterised  by  an  eruption  of  papules,  vesicles, 
and  sometimes  of  pustules.  The  rash  forms  more  or  less  extensive  patches 
of  redness.  These  secrete  a  thin  gummy  fluid  which  dries  into  scales  and 
crusts.  The  disease  is  accompanied  by  much  initation,  and  in  severe  cases 
the  constant  itching  interferes  with  sleep  and  keej)S  the  unfortunate  pa- 
tient in  a  state  of  constant  restlessness  and  distress.  It  may  attack  chil- 
dren of  all  ages,  and  in  infants  especially  (eczema  infantile)  is  apt  to  assume 
a  sub-acute  form  which  persists  for  months  or  even  years  with  varying  in- 
tensity, and  is  very  difficult  of  cure. 

Causation. — Infants  attacked  by  the  disease  are  usually  of  sturdy  build 
without  other  sign  of  ill-health.  In  such  cases  it  is  by  no  means  easy  to 
discover  any  cause  to  which  the  complaint  can  be  attributed.  Often  one 
child  of  the  family  is  alone  affected,  although  the  conditions  of  life  appear 
to  be  the  same  in  the  case  of  the  patient  as  in  that  of  his  more  fortunate 
brothers  and  sisters.  Sometimes,  if  the  child  is  at  the  breast,  we  can  de- 
tect by  careful  inquiry  the  existence  of  dyspepsia  in  the  mother,  or  of  some 
error  in  diet  which  affects  the  quality  of  her  milk.  In  hand-fed  babies  ex- 
cess of  starchy  food  may  seem  to  be  inducing  an  acid  state  of  the  alimen- 
tai-y  canal  which  may  promote  and  maintain  the  cutaneous  eruption.  In 
some  cases  a  gouty  or  rheumatic  family  tendency  may  exist,  and  it  appears 
extremely  probable  that  this  constitutional  disposition  is  often  to  blame 
for  the  occurrence  of  eczema  in  young  children.  It  has  certainly  seemed 
to  me  that  infantile  eczema  is  more  common  in  such  families  than  in  others 
where  no  such  proclivity  exists.  Again,  we  not  unfrequently  find,  especially 
in  scrofulous  subjects,  that  the  eczematous  rash  appears  as  a  sequel  of 
one  of  the  acute  sjDCcific  fevers.  Thus,  it  may  come  on  after  measles,  scar- 
let fever,  or  small-pox.  The  disease  is,  however,  often  met  with  in  cases 
where  no  error  in  mauagement  can  be  discovered,  where  the  animal  func- 
tions appear  to  be  satisfactorily  performed,  where  the  child  has  not  lately 
suffered  from  fever,  and  where  no  family  tendency  to  gout  or  rheumatism 
can  be  found  to  prevail. 

Dentition  is  often  supposed  to  be  an  exciting  cause  of  the  cutaneous 
affection,  and  no  doubt  a  limited  amount  of  eczema  is  often  present  in 
teething  infants.  But  it  is  common  for  the  rash  to  appear  at  the  fifth  or 
sixth  mouth,  before  teething  troubles  have  begun  ;  and  the  eruption  not 
unfrequently  lasts  long  after  the  whole  crop  of  milk-teeth  has  appeared 
through  the  gum. 

In  older  children  mitants  to  the  skin,  such  as  profuse  sweating,  etc., 
may  produce  the  disease  ;  and  at  this  age  excess  of  fruit  and  other  errors 
of  diet  may  lead  to  the  disorder.  Scrofulous  children  are  very  liable 
to  it. 


790  DISEASE  IN   CHILDEElSr. 

Symptoms. — Eczema  usually  begins  as  a  bright  red  patch,  on  which  a 
crop  of  papules  very  quickly  appears,  or  the  surface  becomes  covered  with 
a  number  of  minute,  clear  vesicles.  There  is  great  itching  of  the  inflamed 
portion  of  skin  ;  and  the  friction  to  which  the  part  is  subjected  very  rapidly 
destroys  the  normal  appearance  of  the  rash.  ,  The  papules  are  torn  by  the 
nails,  and  the  vesicles  also  become  ruptured  and  exude  a  thin  fluid  which 
dries  into  scales.  The  parts  affected  are  usually  those  where  the  skin  is 
delicate  and  soft,  such  as  the  folds  of  the  joints,  the  genitals,  the  peri- 
neeum,  the  lips  and  cheeks,  the  inner  sides  of  the  thighs,  and  the  backs  of 
the  legs,  especially  just  above  the  ankles.  It  is,  however,  also  common 
on  the  scalp  ;  but  here  the  disease  usually  assumes  the  pustular  form,  and 
thick  scabs  are  seen,  under  which  there  is  a  jDurulent  fluid.  In  some  chil- 
dren this  variety  is  often  accompanied  by  pediculi. 

The  constitutional  distiu'bance  is  seldom  great ;  there  is  rarely  any 
noticeable  rise  of  temperatiu-e,  and  the  appetite  is  little  impaired.  In 
very  acute  cases,  however,  the  burning  sensation  to  which  the  inflamma- 
tion gives  rise  may  j)roduce  great  distress.  The  child's  sleep  is  disturbed, 
and  all  his  functions  may  be  deranged  by  worry  and  want  of  rest. 

Several  varieties  of  the  disease  are  common  in  children.  Those  which 
will  be  described  are  : — Eczema  simplex,  eczema  rubrum,  eczema  capitis, 
eczema  tarsi,  and  eczema  infantile. 

Eczema  simplex  is  the  commonest  form  of  the  disease.  It  attacks  chil- 
dren behind  the  ears,  at  the  orifices  of  the  nostrils,  on  the  cheeks,  and  in- 
deed on  any  part  of  the  body.  The  rash  occurs  in  patches  of  redness  on 
which  papiiles  or  vesicles  very  quickly  appear,  and  later  pustules  are  gen- 
erally seen.  In  the  latter  case  the  disease  is  often  called  eczema  impetigi- 
nodes.  The  red  rash  exudes  a  gummy  fluid,  which  dries  into  thin  reddish 
or  brownish  crusts.  When  these  are  removed,  the  surface  is  seen  to  be 
red  and  moist,  or  covered  with  fine  scales.  On  hairy  parts,  a  few  pustules 
are  almost  always  seen  as  well.  The  pustules  are  larger  than  the  vesicles, 
and  are  situated  at  the  orifices  of  the  hair-folhcles ;  for  the  hair  can  be 
seen  to  pafs  through  theu"  centre.  They  soon  burst,  and  discharge  their 
contents.  The  fluid  dries  and  forms  thick  crusts,  which  are  sometimes 
turned  up  at  the  edges.  There  is  some  infiltration  of  the  skin  at  the 
afiected  part,  and  a  good  deal  of  itching  and  heat  is  complained  of  by  the 
patient.  The  pustular  form  is  most  common  in  scrofulous  subjects,  but 
may  occiu'  in  others  who  suffer  from  no  such  constitutional  predisposition. 

In  eczema  rubrum  the  inflammation  and  redness  are  very  great,  and 
the  surface  of  the  patch  is  seen  to  be  studded  with  deeper  red  points, 
which  correspond  to  the  orifices  of  the  cutaneous  follicles.  The  secretion 
forms  thick  scabs  under  which  small  excoriations  are  seen — the  conse- 
quence of  rupture  of  the  vesicles.  This  variety  is  especially  frequent  at 
the  folds  of  the  joints,  such  as  the  groins,  the  arm-pits,  and  at  the  backa 
of  the  knees.     It  causes  much  itching. 

Eczema  capitis  occurs  in  the  pustular  (eczema  impetiginodes)  or  the 
scaly  form.  The  exudation  to  which  the  eruption  gives  rise  becomes  en- 
tangled in  the  hairs  and  mats  them  together,  so  that  it  can  with  difficulty 
be  removed.  In  neglected  cases  it  is  not  uncommon  to  find  the  head 
covered  with  a  kind  of  cap  or  large  scab,  composed  of  the  hair  matted 
into  a  mass  by  dried  exudation.  This  feels  soft  and  boggy  to  the  touch, 
from  the  quantity  of  contained  purulent  fluid  which  wells  up  through  any 
opening  in  the  scab.  The  odour  is  most  offensive,  and  usually  in  such 
cases  pediculi  abound.  Superficial  ulcerations  and  small  subcutaneous 
abscesses  may  sometimes  be  seen  on  the  scalp  when  the  crusts  are  re- 


ECZEMA — SYMPTOMS.  791 

moved ;  and  the  glands  of  the  neck  and  those  at  the  back  of  the  head 
often  become  inflamed  and  swollen.  In  very  chronic  cases  the  hairs  may 
fall  out,  but  they  grow  again  when  the  disease  is  at  an  end. 

In  infants  the  scaly  form  is  the  more  common.  The  scalp  may  be  seen 
to  be  covered  with  scabs,  but  exudes  only  a  limited  amount  of  secretion. 

A  variety  of  eczema  capitis  has  been  described  as  impetigo  contagiosa^. 
being  supposed  by  some  authorities  to  be  conveyed  from  one  child  to  an- 
other by  actual  contact.  There  is  no  doubt  that  we  often  find  several 
children  of  the  same  family  suffering  from  impetigo  of  the  scalp  at  the 
same  time,  but  the  contagious  nature  of  the  eruption  is  not  universally 
recognised.  It  is,  indeed,  denied  by  many  good  observers.  Dr.  Tilbury 
Fox,  who  believed  in  the  communicability  of  this  form  of  the  disease, 
states  that  contagious  impetigo  always  begins  as  little  watery  heads. 

In  eczema  tarsi  the  disease  affects  the  edges  of  the  eyelids.  This  form 
is  common  in  scrofulous  children  and  may  be  combined  with  strumous 
ophthalmia  and  conjunctivitis.  A  number  of  pustules  appear  at  the  ori- 
ficeS  of  the  hair-folhcles.  These  burst  quickly  and  form  scabs.  The 
eruption  is  attended  with  considerable  itching  and  some  swelling  of  the 
edges  of  the  lids.  The  margins  of  the  eyeUds  are  scaly  from  small  crusts 
which  cling  round  the  shafts  of  the  hairs  as  these  issue  from  the  follicles. 
The  hairs  are  often  glued  together  by  the  secretion,  and  at  night-time  the 
edges  of  the  eyelids  are  also  very  apt  to  stick  together.  When  the  scabs 
are  removed,  smaU  ulcers  are  often  to  be  detected  on  the  skin  beneath. 
Eczema  tarsi  is  a  very  chronic  complaint.  It  is  often  accompanied  by 
much  weakness  of  the  eyes  and  lachrymation.  If  allowed  to  go  on  it 
eventually  causes  obliteration  of  the  Meibomian  glands  and  hair-foUicles, 
and  the  eyelashes  are  apt  to  fall  out,  or  if  they  remain,  to  grow  irregularly 
and  in  very  inconvenient  directions. 

Eczema  infantile  is  a  very  obstinate  form  of  the  disease.  It  usually  ap- 
pears before  the  end  of  the  sixth  month,  and  attacks  infants  who  in  other 
respects  seem  to  be  in  perfect  health.  It  begins  generally  on  the  cheeks 
and  spreads  thence  to  the  neck,  chest,  arms,  and  body  generally.  At  first 
it  is  not  uncommonly  complicated  by  wheals  of  urticaria.  In  any  case  the 
disease  is  accompanied  by  intense  itching  which  evidently  causes  the 
utmost  distress  to  the  child,  and  often  it  is  necessary  to  secure  his  hands, 
so  as  to  prevent  his  increasing  the  irritation  by  constant  friction.  Even 
when  this  is  done  he  will  rub  his  cheeks  against  the  pillow  of  his  cot  until 
the  skin  is  completely  excoriated,  and  often  wears  the  hair  from  the  back 
of  his  head  by  constant  movement  of  the  occiput  upon  the  pillow  to  relieve 
the  irritation.  The  parts  affected  are  intensely  red,  and  are  rough  and 
scaly  from  drying  of  the  secretion  poured  out  by  the  ruptured  vesicles,  and 
pustules.  In  severe  cases  the  child  hardly  sleeps  at  all  on  account  of  the 
constant  itching.  The  course  of  the  disease  is  seldom  uniform  ;  usually  it 
undergoes  curious  alternations  of  improvement  and  relapse.  An  attack  of 
acute  gastric  catarrh  will  often  cure  the  skin  aflection  completely  for  a 
time,  but  the  eruption  returns  as  badly  as  ever  when  the  gastric  derange- 
ment is  at  an  end. 

A  sturdy  little  boy,  aged  five  months,  had  suffered  for  a  month  from  an 
attack  of  acute  eczema  infantile,  which  occupied  the  whole  of  the  head, 
face,  sides  of  the  neck,  and  the  greater  part  of  the  chest.  The  irritation 
was  extreme.  The  child  had  worn  the  whole  of  the  hair  from  the  back  of 
his  head  by  friction  of  the  occiput  against  the  pillow.  This  infant  had  an 
attack  of  acute  gastric  catarrh  with  violent  and  repeated  vomiting.  The 
eczema  at  once  began  to  fade,  and  in  the  course  of  three  days  had  almost 


792  DISEASE   IN   CHILDREN. 

completely  disappeared.  Directly,  however,  the  vomiting  had  ceased  and 
the  appetite  had  begun  to  return,  the  cutaneous  eruption  reappeared,  and 
in  a  day  or  two  was  as  bad  as  before. 

This  form  of  eczema  often  continues  for  years,  and  may  persist  through- 
out the  whole  of  childhood.  In  such  cases,  however,  the  eruption  gener- 
ally clears  away  completely  from  the  head  and  face,  but  remains  as  a 
patchy  rash,  more  or  less  extensively  diffused  over  the  body  and  limbs. 

Diagnosis. — Eczema  as  a  rule  is  a  disease  which  is  readily  recognised. 
The  diagnostic  characters  of  the  eruption  are  : — A  red,  inflamed,  and  rather 
infiltrated  surface  which  gives  rise  to  extreme  itching,  and  presents  many 
scales  or  crusts,  and  a  more  or  less  punctated  appearance,  i.e.,  the  red- 
dened skin  has  a  dotted  look  from  small  points  of  a  deeper  red  covering 
the  surface  of  the  patch.  It  is  very  important  with  regard  to  treatment  to 
exclude  scabies,  for  this  parasitic  eruption  has  often  the  general  appear- 
ance of  eczema  ;  indeed,  a  true  eczema  is  often  present  on  the  body  ex- 
cited by  the  irritation  of  the  acarus.  In  all  doubtful  cases  the  character- 
istic furrow  produced  by  the  itch  insect  should  be  diligently  searched*  for, 
for  this,  if  discovered,  is  pathognomonic.  It  must  be  remembered  that  in 
young  children  scabies  rarely  affects  the  hands  and  wrists,  but  is  more 
commonly  found  about  the  buttocks,  the  belly,  the  feet,  and  the  ankles. 
Ecthymatous  pustules  seated  upon  the  soles  of  the  feet  are  very  strong 
evidence  in  favour  of  scabies. 

Sometimes  patches  oi psoriasis,  especially  if  the  silvery  scales  have  been 
removed,  bear  a  great  resemblance  to  eczema  in  the  dry  or  chronic  form. 
In  such  cases  we  should  carefully  examine  all  the  patches  discoverable 
about  the  body.  In  eczema  the  patches  are  brighter  in  colour  and  less 
well  defined  at  the  edges,  the  scales  are  thin  and  loosely  attached,  itching 
is  a  marked  feature,  and  the  parts  affected  are  usually  the  flexures  of  the 
joints  and  other  regions  where  the  skin  is  delicate  and  disposed  to  be 
moist.  In  psoriasis  the  patches  are  well  defined  and  paler  in  colour,  the 
scabs  are  thicker  and  more  adherent,  and  itching  is  of  moderate  intensity. 
Moreover,  psoriasis  attacks  by  preference  the  outer  parts  of  the  limbs 
where  the  skin  is  comparatively  thick  and  coarse. 

Syphilitic  eruptions  in  the  infant  are  readily  distinguished  from  eczema 
by  their  more  coppery  tint,  the  absence  of  itching  to  any  notable  degree, 
and  the  presence  of  hoarseness,  snuffling,  and  other  well-marked  signs  of 
the  s;)-philitic  cachexia. 

Eczema  capitis  can  scarcely  be  confounded  with  tinea  tonsurans  or  favus 
by  any  careful  observer.  There  are  no  broken  or  brittle  hairs,  such  as  are 
so  characteristic  of  the  former  disease  ;  and  the  bright  yellow  cup-shaped 
crusts  of  favus  have  no  resemblance  to  the  scabs  of  impetigo  of  the  scalp. 
It  must  be  remembered,  however,  that  a  real  eczema  capitis  may  occur  as 
a  complication  in  a  late  stage  of  tinea  tonsurans,  but  in  such  a  case,  when 
the  eczema  is  cured,  the  broken  hairs  of  the  parasitic  disease  can  be  -dis- 
covered on  careful  examination. 

I  have  known  acute  eczema  in  the  early  stage  to  assume  a  crescentic, 
slightly  papular  form,  which  has  been  mistaken  for  measles  ;  but  the  ab- 
sence of  pyrexia  and  of  cough  or  lachrymation  will  serve  in  such  a  case  to 
exclude  the  exanthem. 

Treatment. — In  cases  of  eczema  we  must  not  confine  ourselves  to  local 
applications  to  the  inflamed  surface.  Often  the  general  health  of  the  child 
will  also  require  attention.  Eczematous  eruptions  are  common  in  chil- 
dren of  scrofulous  constitution  or  debilitated  frame.  In  such  patients  the 
local  remedies  must  be  aided  by  general  tonic  treatment,  if  any  permanent 


ECZEMA — TREATMENT.  .793 

"benefit  is  to  be  obtained.  In  scrofulous  children  the  general  treatment 
recommended  for  that  cachectic  state  should  be  adopted,  and  if  the  child 
is  thin  and  spare,  cod-liver  oil  will  be  found  of  service.  Iron-wine  is  also 
a  valuable  remedy. 

In  obstinate  cases  arsenic  may  be  usefully  combined  with  the  iron,  and 
as  children  bear  arsenic  well  the  drug  can  usually  be  given  in  the  same 
doses  as  are  found  beneficial  in  the  adult.  There  is,  however,  no  advan- 
tage in  cases  of  arsenic  in  pushing  the  dose  to  the  utmost  limits  of  toler- 
ation. It  is  seldom  necessary  to  exceed  five  drops  of  Fowler's  solution 
three  times  a  day. 

If  any  tendency  to  acidity  and  flatulence  is  noticed,  the  alkalies  are  some- 
times of  service,  and  the  quantity  of  fermentable  matter  allowed  in  the 
diet  should  be  restricted.  Too  much  importance,  however,  need  not  be 
attached  to  the  subject  of  diet  in  the  treatment  of  eczema.  If  a  case  is 
obstinate  and  resists  ordinary  remedies,  I  have  not  found  the  prohibition 
of  sweets  and  fruit  of  much  value  in  promoting  a  cure.  Other  observers, 
however,  seem  to  have  met  with  more  success.  In  cases  of  flabby  (not 
plethoric)  children,  Mr.  B.  Squire  advocates  an  almost  total  deprivation  of 
the  fat-forming  elements  of  food.  He  allows  milk  diluted  with  twice  its 
bulk  of  water  ;  dry  toast,  or  dry  biscuits ;  lean  beef  or  mutton  with  all 
the  fat  carefully  removed ;  white  fish  broiled  ;  green  vegetables  (but  not 
potatoes,  turnips,  carrots,  or  other  vegetable  roots),  and  cooked  fruit  un- 
sweetened. Mr.  Squire  states  that  great  improvement  is  seen  in  these 
cases  within  ten  days  of  beginning  this  diet. 

In  all  cases  the  digestive  organs  should  be  attended  to,  and  any  de- 
rangement remedied  as  quickly  as  possible.  Constipation  must  be  re- 
lieved, looseness  of  the  bowels  arrested,  and  it  should  be  our  care  to  see 
that  the  animal  functions  generally  are  in  good  order. 

In  cases  of  acute  eczema  tonic  treatment  is  not  always  the  best  suited 
to  cause  the  disappearance  of  the  eruption.  The  disease  sometimes  attacks 
sturdy,  florid  children,  with  a  good  colour  and  plethoric  habit.  These 
cases  should  be  treated  with  a  mercurial  purge,  followed  by  sahne  laxa- 
tives to  keep  up  a  gentle  action  upon  the  bowels  for  several  days.  The 
child  should  take  no  meat,  but  should  be  put  upon  milk,  broth,  light  pud- 
dings, and  bread-and-butter.  Again,  in  cases  where  there  is  an  evident 
tendency  to  rheumatism,  or  a  strong  gouty  element  in  the  family  history, 
guaiacum  often  has  a  very  marked  influence  in  curing  the  disease.  The 
simple  tincture  is  the  best  preparation ;  it  should  be  given  in  doses  of 
twenty  minims  three  times  a  day  (to  a  child  of  ten  years  old). 

The  local  treatment  is  of  great  importance  in  the  treatment  of  eczema. 
When  the  eruption  is  very  acute,  stimulating  ointments  should  not  be  used, 
but  the  part  should  be  kept  moist  with  a  simple  water-dressing,  or  be 
bathed  frequently  with  bran-water  made  by  pouring  boiling  water  upon 
bran  and  allowing  it  to  cool.  Dr.  E.  Liveing  recommends  the  applica- 
tion to  the  aifected  surface  of  a  powder  composed  of  three  drachms  each 
of  oxide  of  zinc  and  starch,  and  thirty  grains  of  camphor.  Over  this  is  to 
be  placed  a  warm  hnseed-meal  poultice. 

In  a  later  stage  alkaline  warm  baths  are  useful.  Dr.  Buckley  recom- 
mends that  for  this  purpose  the  carbonates  of  soda  and  potash  and  the 
biborate  of  soda  be  used  ;  two  to  four  teaspoonfuls  of  each  to  the  gallon  of 
water.  To  these  two  to  four  teaspoonfuls  of  dry  starch  are  added.  This 
bath  should  be  used  without  soap,  the  child  being  merely  soaked  and 
bathed  in  the  medicated  water.  After  ten  minutes  or  so  he  is  removed, 
dried  without  friction,  and  then  well  dusted  over  the  body  with  lycopo- 


794  DISEASE   IX   CHILDREN. 

dium  powder.  Much,  washing  is  to  be  forbidden  in  cases  of  acute  eczema, 
as  it  is  said  to  injure  the  process  of  repair.  Dr.  Buckley  only  allows  it 
wben  the  accumulation  of  exuded  matter  prevents  the  ointments  from 
reaching  the  diseased  surface. 

A  useful  foiTa  of  bath  is  made  by  medicating  the  water  with  Wright's 
liq.  carbonis  detui'gens  in  the  proportion  of  two  drachms  to  the  gallon. 
This  can  be  given  at  fii-st  every  night  for  half  an  hoiu' ;  afterwards  on 
alternate  nights.  Local  jDatches  of  eczema  are  often  benefited  and  in 
many  cases  quickly  cured  by  keeping  the  part  constantly  moist  with  a 
lotion  composed  of  two  drachms  of  the  Hq.  carbonis  deturgens  to  ten 
ounces  of  water.  To  be  effectual,  however,  the  moistened  rags  in  contact 
with  the  affected  surface  should  never  be  allowed  to  get  dry. 

Zinc  and  lead  ai'e  two  of  the  most  valued  applications  for  eczematous 
jDatches.  In  the  moist  variety  a  salve  composed  of  oxide  of  zinc  and  the 
solution  of  the  subacetate  of  lead — a  drachm  of  each  to  the  ounce  of  vaseline 
— is  very  useful.  In  the  dry,  scaly  form  of  the  rash  this  ointment  is  made 
more  efficacious  by  the  addition  of  twenty  to  thirty  gTains  of  the  ammonio- 
chloride  of  mercury  and  a  drachm  of  the  hq.  carbonis  deturgens.  If 
itching  be  very  distressing,  the  following  application,  taken  fi'om  the 
pharmacopoeia  of  University  College  Hospital,  is  of  gi'eat  service : — 

1} ,   Calamine  (zinci  carb. ) gr.  xl. 

Zinci  oxidi gr.  xxx. 

Glycerini Til  ^^^^ 

Aquam  rosse ad.  3  j. 

M.     Sig.  — To  be  painted  with  a  brush  on  the  affected  part. 

In  eczema  capitis  the  crusts  must  be  first  carefully  removed.  This  is 
best  done  by  covering  them  at  night  with  a  thick  layer  of  lard  and  placing 
over  this  a  large  linseed-meal  poultice.  In  the  morning  the  softened 
crusts  can  be  picked  off  with  forceps  or  bathed  away  with  warm  water. 
When  completely  cleansed  the  scalp  must  be  anointed  with  ammonio- 
chloride  of  mercury  ointment  diluted  with  an  equal  proportion  of  lard  ; 
or  we  may  use  the  salve  composed  of  oxide  of  zinc  and  subacetate  of  lead 
already  referred  to.  Children  who  have  this  form  of  impetiginous  eczema 
in  a  severe  degree  are  usually  of  strumous  constitution  and  require  tonic 
treatment.  In  obstinate  cases  of  eczema  of  the  scalp  the  disease  can  often 
be  cured  by  tany  applications.  Half  an  ounce  of  common  tar,  oil  of  cade, 
or  oil  of  birch  (olei  rusci)  may  be  added  to  two  ounces  of  glycerine  of 
starch.  This  can  be  painted  over  the  head  twice  a  day.  In  very  chronic 
cases  one  thorough  application  of  undiluted  liquid  tar  wiH  sometimes  x^i'o- 
duce  a  complete  cure  of  the  disease. 

Eczema  of  the  nostrils  is  usually  cured  very  quickly.  The  crusts  must 
be  fii'st  removed  from  the  nostrils  by  softening  them  with  an  oiled  plug 
and  afterwards  bathing  with  warm  water.  Ungnientum  hydrargyri  am- 
monio-chloridi  can  then  be  applied  freely  to  the  interior  of  the  nostril  with 
a  folded  morsel  of  hnen  rag  or  hnt. 

In  eczema  tarsi  it  is  often  necessary  to  pull  out  the  eyelashes,  and  in 
obstinate  cases  the  operation  is  almost  always  necessary.  The  scabs  must 
be  carefuUy  removed  with  fine  forceps  or  the  head  of  a  large  pin,  and  the 
edges  of  the  lids  be  afterwards  smeared  with  any  of  the  ointments  which 
have  been  recommended.  A  mild  mercurial  salve,  perhaps,  answers  the 
best. 

Eczema  infantile  is  often  a  very  obstinate  complaint,  and  from  the  dis- 


ECZEMA — TREATMENT.  795 

tress  it  occasions  to  tlie  infant  and  through  him  to  his  mother  or  nurse, 
whose  sleep  is  necessarily  broken  by  the  wakefulness  of  her  charge,  is  one 
upon  which  it  is  important  to  make  some  immediate  imjoression.  When 
the  disease  is  very  acute  and  the  skin  red  and  intensely  irritable,  a  rapid 
improvement  is  pi'oduced  by  large  doses  of  quinine.  I  was  led  to  employ 
the  remedy  in  these  cases  from  noticing  its  striking  ijifluence  upon  chronic 
urticaria  in  young  childi-en.  In  eczema  a  dose  of  two  grains  given  at  bed- 
time to  a  child  of  six  or  eight  months  old,  and  repeated  every  second 
night,  reduces,  in  a  remarkable  manner,  the  general  redness,  soothes  the  ir- 
ritation, and  consequently  greatly  reUeves  the  child's  distress.  He  begins 
to  sleep  better  at  night,  and  in  the  daytime  is  less  ii'ritable  and  fractious. 
Perch]  on de  of  mercury,  given  internally  in  small  doses,  is  also  a  valuable 
remedy.  A  child  of  eight  months  old  may  take  ten  or  fifteen  drops  of  the 
solution  (P.  B.)  thi'ee  times  a  da}-,  and  the  eruj)tion  often  seems  to  im- 
prove greatly  under  its  use.  Tbu'ty  or  forty  drops  of  the  infusion  of 
rhubarb  with  a  few  grains  of  bicarbonate  of  soda,  given  regularly  two  or 
three  times  a  day,  will  often  also  be  followed  by  considerable  benefit. 

As  in  older  children,  the  simple  tincture  of  gniaiacum  is  a  remedy 
which  sometimes  produces  veiy  rapid  and  decided  improvement.  I  have 
seen  the  fiery  redness  of  the  general  surface  fade,  and  the  itching  almost 
entirely  cease  under  a  week's  use  of  this  remedy  given  in  doses  of  ten 
minims  three  times  a  day.  When  it  succeeds,  guaiacum  seems  to  take  all 
the  acuteness  out  of  the  complaint,  and  reduces  the  eruption  to  a  common 
vesiculo -pustular  rash  which  yields  readily  to  ordinary  apphcations. 

The  alkahne  bath  recommended  by  Dr.  Buckley,  and  the  bath  medi- 
cated with  the  liq.  carbonis  deturgens  (see  page  794),  are  both  very  use- 
ful. They,  the  latter  esjDecially,  have  great  influence  in  relieving  the  itch- 
ing, and  the  calamine  and  zinc  application  already  referred  to  may  be 
used  with  the  same  object.  Too  frequent  washing  of  the  infant  is  bad  in 
these  cases,  and  the  mother  should  be  cautioned  against  disturbing  the 
treatment  by  the  too  energetic  use  of  soap  and  water. 

Vaccination  of  the  child  is  said  in  some  obstinate  cases  to  produce  a 
complete  ciu'e  of  the  disease,  and  many  observers  have  borne  testimony  to 
the  occasional  value  of  this  method  of  treatment.  In  successful  cases  the 
eczematous  rash  clears  away  completely  in  from  one  to  four  weeks  after 
the  operation. 

A  method  of  treatment  by  covering  the  affected  suirface  with  some  im- 
permeable material,  such  as  caoutchouc  cloth,  so  as  completely  to  exclude 
the  air,  has  been  found  useful  in  many  cases.  According  to  E.  Bessener 
this  plan  is  especially  applicable  to  cases  of  eczema  of  the  scalp  where 
there  is  much  secretion.  The  india-rubber  sheeting  must  be  adapted  accu- 
rately to  the  head,  so  as  to  fit  hke  a  skull-cap,  and  must  be  kept  scrupu- 
lously clean,  being  regularly  removed  for  washing  and  drying.  By  this 
means  speedy  improvement  is  said  to  be  effected  even  in  obstinate  cases, 
so  that  the  eruption  wiU  quickly  yield  to  the  ordinary  ointments. 


CHAPTEE  lY. 

MOLLUSCUM   CONTAGIOSUM. 

MoLLTJscuM  contagiosum  is  a  disease  more  common  in  childhood  than  in 
after-life.  It  is  often  seen  in  London  childi-en,  especially  amongst  the 
poor,  but  appears  to  be  less  prevalent  in  country  districts,  or  even  in  other 
large  towns  in  England.  The  contagious  nature  of  the  disease  is  now  well 
estabhshed.  It  may  be  communicated  by  one  child  to  another,  or  by  a 
sucking  infant  to  its  mother's  breast,  and  Dr.  E.  Liveing  states  that  he  has 
seen  nine  children  of  the  same  school  all  affected  vdtli  luolluscum  at  the 
same  time.  In  addition  to  being  contagious  the  disease  may  also  arise 
spontaneously. 

Morbid  Anatomy. — The  exact  seat  of  molluscum  contagiosum  is  still  a 
matter  of  debate.  Many  observers  hold  the  view  that  the  httle  tumoiu'S 
have  their  seat  in  the  sebaceous  glands  of  the  skin.  This  was  long  ago 
denied  by  Virchow,  and  after  tliis  authority  others  have  supported  the 
opinion  that  the  bodies  consist  of  a  morbid  gTowth  of  the  cells  of  the  cutis. 
Sections  of  the  tumom's  show  that  some  are  simple  cyst-hke  bodies,  others 
are  lobulated  and  surrounded  by  a  fibrous  capsule  fi'om  which  fine  septa 
pass  between  the  lobules.  The  subject  has  been  lately  investigated  anew 
by  Dr.  Sangster,  who  concludes,  as  a  result  of  his  observations,  that  mol- 
luscum contagiosum  is  a  disease  of  the  epidermis  in  which  three  layers  take 
part.  The  external  portion  is  formed  by  the  cells  of  the  rete,  for  on  care- 
ful vertical  section  of  the  earhest  specimens  procurable  the  rete  is  seen  in 
direct  continuity  with  the  lobular  expansions  of  the  new  gi'owth.  The 
cells  probably  undergo  simple  hypei-plasia,  and  those  placed  at  the  border 
are  elongated  and  vertical.  Next  to  these  is  a  gTanular  layer  composed  of 
polygonal  cells  more  or  less  infiltrated  mth  fat-globules.  In  the  centre 
are  roundish  bodies,  translucent  and  watery-looking,  which  are  called 
"molluscum  corpuscles."  All  these  are  aiTanged  in  masses  which  he  in 
the  meshes  of  a  granular  reticulum.  The  tumour  is  covered  by  the  more 
superficial  layer  of  the  corium,  and  at  its  base  is  a  network  of  fine  ves- 
sels. 

Symptoms. — Molluscum  contagiosum  appears  in  the  form  of  small, 
white,  hard,  translucent  swelhngs  which  gTadually  increase  in  size  tmtil 
they  reach  the  dimensions  of  a  pea,  or  even  a  nut.  Their  form  is  circular, 
with  a  flattened  top,  and  at  this  part  is  seen  a  minute  depression,  which  is 
supposed  by  those  who  recognise  the  sebaceous  origin  of  the  tumours  to 
be  the  mouth  of  the  sebaceous  cyst.  The  smaller  growths  are  usually 
sessile  ;  the  larger  are  pedunculated.  A  milky-looking  thickish  juice  can 
be  squeezed  out  of  the  central  depression,  especially  if  a  puncture  has  been 
previously  made  mth  the  point  of  a  lancet. 

There  is  no  itching  or  uneasiness  connected  with  the  growths  in  their 
ordinary  state,  but  sometimes  one  will  inflame  and  be  converted  into  a 
pustule.     When  left  alone  the  tumom'S  gradually  diy  up,  leaving  some 


MOLLUSCUM   ^'ONTAGIOSUM — DIAGNOSIS — TREATMENT.       797 

thickening  at  theii"  site.  The  older  ones  are  usually  succeeded  by  a  fresh 
crop. 

Theii"  seat  is  usually  the  skin  of  the  face,  the  eyelids,  or  the  neck,  but 
they  may  be  also  seen  on  the  chest,  abdomen,  genitals,  and  inner  part  of 
the  thighs. 

Diagnosis. — These  tumours  must  not  be  confounded  with  the  moUus- 
cum  fibrosum,  which  is  altogether  a  different  disease.  These  are  small 
bodies  of  sohd,  somewhat  gelatinous  stnicture,  and  consist,  according  to 
Kokitansky,  of  a  protrusion  of  the  corium,  "  which  is  pushed  forwards  by 
accumulation  of  young,  gelatinous  connective  tissue  in  one  of  its  deepest 
meshes."  They  have  no  umbilication  like  the  contagious  moUuscum,  and 
no  milky  juice  can  be  obtained  from  them  by  pressure. 

Treatment . — The  smaller  tumours  must  be  touched  with  nitric  acid  or 
other  strong  caustic.  The  larger  must  be  divided  with  a  lancet  and  the 
contents  squeezed  out.     A  Httle  caustic  can  be  afterwards  applied. 


CHAPTER  Y. 

THE   PAEASITIC   DISEASES. 

The  varieties  of  parasitic  disease  of  the  skin  which  will  be  described  are : — 
Scabies,  due  to  the  iiTitation  of  the  acarus  scabiei  or  the  itch-insect ;  and 
certain  vegetable  parasitic  fungi,  viz.,  tinea  tonsurans  and  tinea  favosa. 

SCABIES. 

The  symptoms  to  which  the  acarus  scabiei  gives  rise  are  due  to  the  irrita- 
tion produced  by  the  insect  as  it  bui'rows  in  the  skin.  The  female  acarus 
works  its  way  into  the  epidermis  and  forms  a  narrow  tunnel  called  "  cuni- 
culus."  The  intense  itching  thus  occasioned  forces  the  child  to  reheve  him- 
self by  scratching ;  and  the  consequences  are  seen  in  the  wheals,  papules, 
vesicles,  and  even  pustules  which  in  a  typical  case  are  mixed  up  together  in 
a  manner  which  is  very  characteristic  of  the  complaint. 

The  cuniculus  or  fuiTOW  appears  as  a  whitish  curved  hue,  which  when 
newly  formed  may  be  easily  overlooked  ;  and  in  children,  especially  in  in- 
fants, who  are  well  tended  and  frequently  washed,  may  escape  notice  alto- 
gether unless  naiTOwly  searched  for.  In  hospital  patients  they  are  readily 
discovered  as  they  become  darker  and  more  distinct  from  small  specks 
of  du't.  The  fuiTOw  is  about  the  eighth  of  an  inch  in  length,  but  may  be 
longer,  and  to  the  naked  eye  closely  resembles  the  scratch  of  a  pin.  Viewed 
with  a  lens  it  has  a  dotted  look,  and  sometimes  at  one  extremity  a  small 
white  object  can  be  detected,  which  is  the  female  insect.  With  care  this 
may  be  extracted  with  the  point  of  a  pin. 

In  infants  the  furrows  are  rarely  seen  on  the  wi'ist  and  between  the  fin- 
gers as  the}'  are  in  older  childi'en  and  in  the  adult.  In  these  young  sub- 
jects they  must  be  searched  for  on  the  abdomen,  the  waist,  the  buttocks, 
round  the  ankles,  and  on  the  soles  of  the  feet ;  but  in  babies  in  well-to-do 
famihes,  where  cleanliness  is  properly  attended  to,  the  sign  may  elude  the 
closest  inspection.  In  young  children  after  the  age  of  infancy  they  are 
also  usually  seated  on  the  buttocks,  feet,  and  ankles.  It  is  only  in  childi-en 
of  five  or  six  years  and  upwards  that  they  are  often  to  be  detected  between 
the  fingers.     The  scalp  and  face  are  rarely  attacked. 

The  itching  to  which  the  presence  of  this  parasite  gives  rise  is  of  the 
most  distressing  character,  and  at  night  may  be  extreme.  The  child  will 
be  seen  to  dig  his  nails  into  the  skin  in  his  efforts  to  obtain  rehef.  As  a 
consequence  we  find  reddened  linear  scars  from  small  furrows  made  by 
the  nails ;  and  as  another  result  of  the  violent  scratching,  can  usually  dis- 
cover small  papules,  often  excoriated  and  tipped  with  a  minute  crust  of 
dried  blood,  little  vesicles,  and  even  large  deep-seated  pustules.  These  lat- 
ter are  often  seen  on  the  soles  of  the  feet.  In  very  delicate  subjects  a  real 
eczema  may  be  set  up  either  by  the  iiTitation  of  the  nails  or  of  the  appHca- 


THE   PARASITIC   DISEASES — SCABIES — TINEA   TOI^SURANS.      799 

tions  used  for  the  destruction  of  the  parasite ;  and  large  wheals  of  urticaria 
are  far  from  uncommon. 

Diagnosis. — The  simultaneous  appearance  of  a  variety  of  eruptions  on 
the  body  of  an  infant  is  a  very  suspicious  featui'e ;  and  if  with  a  lens  we 
can  succeed  in  discovering  the  characteristic  furrow,  no  doubt  can  remain 
as  to  the  nature  of  the  comj^laint.  In  the  case  of  an  infant,  the  hands  of 
the  mother  or  nurse  mil  be  always  found  to  be  affected.  Therefore  in  ever}^ 
case  of  doubt  a  careful  insj)ection  should  be  made  of  the  hands  of  the  at- 
tendant. In  searching  for  the  furrow  in  young  children  attention  should 
be  always  especially  directed  to  the  buttocks,  abdomen,  and  the  soles  of  the 
feet.  In  older  children  the  furrows  may  be  seen  between  the  fingers  and 
on  the  wrist  as  in  the  adult ;  and  as  at  this  age,  especially  in  boys,  cleanliness 
of  these  parts  is  often  neglected,  the  cuniculus  seldom  fails  to  be  discovered. 

Treatment. — Scabies  can  only  be  cured  by  local  treatment  which  kills  the 
parasitic  insect,  and  the  favourite  and  most  efficacious  remedy  is  the  applica- 
tion of  sulphur  ointment  to  the  skin.  It  must  be  remembered  that  in  chil- 
dren, in  infants  especialty,  the  skin  is  dehcate  and  sensitive  to  irritants. 
Therefore,  while  care  is  taken  to  make  effectual  use  of  the  salve  so  that  the 
acarus  may  be  destroyed,  Ave  should  avoid  maintaining  the  cutaneous  irrita- 
tion by  too  prolonged  or  too  zealous  application  of  the  ointment.  At  night- 
time the  child  should  be  first  thoroughly  washed  over  the  whole  body  with 
a  strong  soap,  and  be  then  well  bathed  with  warm  water,  so  as  completely 
to  soften  the  skin  and  lay  open  such  furrows  as  may  be  present  by  destroy- 
ing their  roofs.  He  should  then  be  well  dried,  and  an  ointment  made  of 
half  a  drachm  of  precipitated  sulphur  to  the  ounce  of  lard  must  be  rubbed 
into  the  skin  of  the  whole  body  except,  of  course,  the  head.  It  is  important 
that  the  salve  be  rubbed  into  the  skin  and  not  merely  smeared  over  the 
surface.  In  the  morning  the  skin  should  be  again  thoroughly  washed. 
This  one  apphcation  will  cure  the  disease  in  most  children.  It  is  advisable, 
however,  to  rub  a  little  of  the  ointment  into  the  parts  which  seem  to  have 
been  especially  affected  for  two  or  three  nights  longer.  We  should  then 
pause  to  watch  the  effect  of  the  treatment.  Itching  often  continues  for 
some  time  after  the  parasites  have  been  destroyed,  as  a  consequence  of  the 
various  forms  of  eruption  set  up  by  the  acarus.  In  cases  where  it  is  doubt- 
ful whether  the  disease  be  cured  or  not,  Dr,  E.  Liveing  recommends  an 
ointment  made  with  the  balsam  of  Peru  (  3  ij-  to  the  ounce  of  lard). 

If  it  be  thought  desirable  to  disguise  the  sulphur  in  the  ordinary 
ointment,  this  can  be  done  by  a  drop  of  creasote  or  oil  of  bergamot.  Dr. 
Liveing  prefers  the  precipitated  to  the  sublimed  sulphur,  as  being  in  a 
finer  powder,  and  less  irritating  to  the  skin. 

Instead  of  suljphur,  an  ointment  may  be  used  of  liquid  styrax  (one 
part)  and  lard  (two  parts),  or  of  powdered  stavesacre  and  lard  (  3  ij-  to 
the  ounce)  ;  but  these  are  distinctly  inferior  to  the -sulphur.  Ointments 
containing  carbolic  acid  have  also  been  made  use  of.  It  is  advisable  to 
well  scald  the  underclothing  of  the  patient,  and  after  recovery  to  bake  the 
outer  garments,  so  as  to  insure  the  destruction  of  stray  insects. 


TINEA  TONSURACfS. 

Tinea  tonsurans  is  pecuharly  a  disease  of  early  Hfe.  This  affection  is 
practically  confined  to  children,  and  in  the  form  of  ringworm  of  the  scalp 
is  one  of  the  most  obstinate  and  contagious  of  complaints.  The  disease  is 
due  to  the  presence  of  a  fungus — the  tricophyton  tonsurans — which  grows 


800  DISEASE   IN"   CHILDEEW. 

in  the  internal  root-slieath  within  the  follicle,  and  the  fine  mycelium  fila- 
ments penetrate  into  the  hair  between  the  fibres.  These  filaments  are 
composed  of  cylindi-ical,  tube-hke  bodies  united  in  chains.  At  the  surface 
of  the  hail*  the  spores  of  the  tricophyton  are  collected  into  little  globular 
masses  called  conidia,  and  in  very  old-standing  cases  these  are  also  seen 
to  fill  almost  the  whole  thickness  of  the  hair.  As  a  consequence  of  the 
presence  of  the  parasitic  fungus  the  hau-s  are  greatly  thickened  ;  their 
colour  changes  to  a  dull  gray  tint,  and  their  brittleness  causes  them  to 
break  off  short  at  a  point  immediately  above  the  follicle  out  of  which 
they  issue.  The  fungus  is  seen  not  only  in  the  substance  of  the  hair,  and 
coating  their  shafts,  but  also  as  a  more  or  less  continuous  layer  on  the  sur- 
face of  the  scalp.  Through  this  covering  the  free  ends  of  the  stubbly  hairs 
can  be  seen  as  black  points.  Later,  as  the  parasitic  matter  accumulates, 
the  stumps  of  hair  become  completely  ensheathed  in  the  mycehum  coat- 
ing so  that  their  situation  is  only  shown  by  a  jorojection  of  the  surface  of 
the  layer.  Bazin  has  compared  the  appearance  thus  produced  to  that  of  a 
surface  covered  with  hoar-frost. 

In  very  old-standing  cases,  acute  inflammation  may  be  set  up  in  the 
hair-follicles.  This  may  lead  to  complete  destruction  of  the  hairs,  so  that 
the  part  of  the  scalp  afiected  remains  partially  bald. 

Symptoms. — On  the  scalp  ringworm  is  seen  in  more  or  less  circular 
patches.  These  in  the  earhest  stage  axe  shghtly  raised  above  the  surface, 
and  cause  considerable  itching.  The  hairs  are  not  broken  off,  and  have 
almost  a  natural  appearance  ;  but  they  will  be  fovuid  to  be  very  brittle,  so 
that  they  generally  break  if  an  attempt  is  made  to  extract  them.  As  the 
disease  proceeds  the  patches  become  distinctly  circumscribed,  and  of  a 
pale  fawn  or  slate-gray  colour.  Their  surface  is  covered  by  a  thick  scurf 
formed  of  epithelial  scales  mixed  with  the  fungoid  growth.  This  scurf 
gives  a  frosted  appearance  to  the  patch,  and  adheres  to  the  shafts  of  the 
hairs  as  these  emerge  from  the  follicles.  The  patches  are  not  entirely 
covered  by  the  short  bristly  hairs,  for  in  many  places  these  have  fallen 
out,  leaving  the  surface  bare.  Those  which  remain  are  short  and  twisted. 
They  look  as  if  cut  off  about  a  line  or  two  above  the  surface  of  the  scalp  ; 
and  are  thickened,  dull  in  colour,  and  sometimes  loose  in  their  sockets. 
If  the  seui'f  has  accumulated  to  a  great  thickness,  the  ends  of  the  hairs 
may  be  completely  concealed  from  view. 

The  number  of  patches  existing  at  the  same  time  varies.  Sometimes 
they  are  very  numerous  ;  indeed,  in.  certain  cases,  the  disease  takes  on  a 
difiuse  form,  in  which  little  groups  of  scaly  patches  with  bristly  stumps  of 
hairs  are  seen  scattered  over  the  surface  of  the  head. 

"When  the  tinea  is  seated  on  the  skin  of  the  body  it  is  called  tinea  cir- 
cinata.  This  is  also  a  very  common  form  of  the  disease,  and  is  generally 
found  on  the  face  and  neck,  although  it  may  occupy  any  part  of  the  body 
or  limbs.  It  is  seen  as  a  slightly  elevated,  roundish  patch,  of  a  light-  red 
colour,  and  of  the  size  of  a  small  pea.  This  begins  to  extend  at  its  edges, 
and  as  the  circumference  spreads,  the  central  part  fades  and  becomes  less 
prominent,  so  that  the  circular  patch  is  converted  into  a  ring  which  con- 
tinues to  enlarge.  With  a  lens  the  surface  affected  is  seen  to  be  covered 
with  branny  scales  ;  and  fine  vesicles  are  noticed  at  the  margins.  If  two 
adjacent  rings  happen  to  touch  one  another,  morbid  action  at  the  point  of 
contact  undergoes  no  further  extension.  In  this  way  curiously  irregular 
shapes  are  often  produced.  In  the  central  part  of  the  ring  the  skin, 
although  of  comparatively  healthy  appearance,  has  yet  a  yellowish  tint, 
and  a  roughened  look  from  small  scales.     These  spots  cause  a  great  deal 


THE   PAEASITIC   DISEASES — TINEA   TOISTSUEANS.  801 

of  irritation,  and  the  fungus  is  no  doubt  often  conveyed  by  the  child's 
nails  from  the  body  to  the  scalp. 

The  general  health  of  children  affected  with  ringworm  is  often  unsatis- 
factory ;  and  the  complaint  seems  to  attack,  by  preference,  Aveakly  and 
scrofulous  subjects.  The  latter,  especially,  have  seemed  to  me  to  be  pecu- 
liarly prone  to  the  disorder. 

Diagnosis. — In  cases  of  ringworm  of  the  scalp  the  chief  diagnostic 
point  is  the  appearance  of  little  rounded,  scaly  patches,  on  the  surface  oi 
which  the  hairs  are  thick,  dull  in  colour,  and  broken  short  off  just  above 
the  follicles.  If  one  of  these  short  hairs  be  removed  with  a  paii-  of  fine 
forceps,  and  placed  with  a  drop  of  liq.  potassse  under  the  microscope,  the 
characteristic  masses  of  sjpores  and  mycelium  filaments  will  be  readily 
distinguished.  If  the  hair-stump  be  allowed  to  soak  in  the  drop  of  potash 
solution  for  an  hour  or  two  before  inspection,  the  parasitic  fungus  will  be 
more  readily  detected. 

At  an  earlier  period  than  this  the  complaint  is  less  easy  to  recognise. 
It  is,  however,  of  great  importance  to  detect  the  affection  in  its  early  stage. 
It  often  happens  that  when  one  child  of  a  family  suffers  from  tinea  tonsu- 
rans one  of  his  brothers  or  sisters  is  brought  for  examination,  because  he 
has  been  noticed  to  have  some  irritation  of  the  scalp.  If,  in  such  a  case, 
ringworm  be  present,  we  shall  find  one  or  two  small  rounded  patches, 
roughened  with  fine  scales  ;  and  shall  notice  that  although  no  stumpy 
hairs  are  to  be  seen,  and  the  hairs  have  a  natural  appearance,  they  are  yet 
unusually  brittle,  so  that  they  break  off  when  an  attempt  is  made  to  pull 
them  out  with  the  forceps.  From  the  first,  therefore,  in  ringworm  the 
hairs  are  brittle  ;  and  at  an  early  period  of  the  disease  the  circular  shape 
of  the  patch  on  the  scalp,  and  the  brittleness  of  the  hairs  growing  upon  it, 
are  the  two  points  of  chief  diagnostic  value. 

An  important  question,  and  one  upon  which  our  opinion  is  often  re- 
quired, is  that  of  whether  in  a  given  case  the  child  is  well.  To  settle  this 
point  correctly  requires  a  very  careful  examination  of  the  scalp.  If  any 
diseased  stumps  of  hairs  remain  the  complaint  is  not  entirely  eradicated. 
The  child  is  therefore  still  a  source  of  infection  to  others,  and  is  him- 
self liable  to  a  relapse.  Even  a  bald  patch  from  which  the  hairs  have  been 
carefully  extracted  is  not  to  be  considered  well.  Often  after  an  interval 
the  stumps  will  shoot  up  again,  the  diseased  balb  of  the  hair  having  been 
left  in  the  follicle.  It  is  not  until  the  part  lately  the  seat  of  the  ringworm 
is  seen  to  be  covered  with  a  fine  downy  growth,  in  which  no  single  stump 
of  the  old  crop  can  be  detected,  that  it  can  be  said,  confidently,  to  be  free 
from  disease. 

In  some  cases  a  difficulty  is  occasioned  by  the  presence  of  eczema 
which  has  invaded  the  scalp  towards  the  end  of  an  attack  of  ringworm. 
When  this  happens  the  evidences  of  ringworm  may  be  quite  concealed  by 
the  complication.  We  must  therefore  withhold  a  positive  opinion  until 
the  eczema  has  been  cared. 

Tmea  circinata  is  distinguished  by  its  annular  shape,  and  in  cases  of 
doubt  by  examination  under  the  microscope  of  a  scraping  from  the  skin 
of  the  patch.  The  spot  selected  for  this  purjDose  should  be  a  part  of  the 
ring  towards  the  inner  margin.  This  should  be  gently  scraped,  and  the 
scaly  matter  removed  is  to  be  placed  under  the  microscope,  with  a  drop 
of  liq.  potassse.  The  jointed  mycelium  will  then  be  recognised,  and  a  few 
spores  will  usually  be  seen. 

Treatment. — In  cases  of  ringworm  of  the  scalp,    the  measures  to  be 
adopted,  and  the  probable  efficacy  of  the  treatment,  vary  considerably,  ac- 
51 


802  DISEASE  IX   CHILDEEX. 

cording  as  tlie  disease  is  of  recent  or  remote  origin.  Eecent  cases  can 
usually  be  quickly  cured,  but  chronic  cases  resist  treatment  with  singular 
obstinacy. 

Treatment  -^ill  also  vary  according  to  tlie  age  of  the  patient.  Eing- 
■tt^orm  can  only  be  cured  by  local  applications,  and  the  measures  to  be 
adopted  consist  of  the  use  of  two  classes  of  remedies,  ^iz..  those  which  irri- 
tate the  skin  and  destroy  the  fungus,  by  exciting  inflammation  in  the  fol- 
licle, and  those  which  kill  the  parasite  without  producing  inflammation. 
Of  these  two  classes  the  first  is  not  suitable  to  very  yoimg  patients.  Bhs- 
ters  and  violent  caustics  are  dangerous  remedies  in  the  case  of  infants  ; 
and  on  account  of  the  pain  they  excite  are  not  to  be  used  carelessly  even 
on  older  subjects. 

In  infants  and  young  children  it  will  be  usually  sufficient  to  wash  the 
head  thoroughly  with  soap  and  hot  water  every  night,  and  after  careful 
di-ying  to  paint  the  patch  with  tincture  of  iodine.  After  a  few  days  the 
application  can  be  changed  to  the  unguentum  hydrargpi  ammonio-chloridi 
(P.  B. )  diluted  with  an  ecjual  proxDortion  of  lard  ;  or  equal  parts  of  this 
salve  and  the  unguentum  sulphims  may  be  made  use  of.  Either  of  these 
must  be  well  rubbed  into  the  afiected  parts  of  the  scalp.  Another  useful 
application  is  the  glycerine  of  carbolic  acid  diluted  with  a  third  part  of 
glycerine.  This  may  be  painted  on  the  patch  with  a  stiff  brush,  or  rubbed 
in  with  a  piece  of  sponge  tied  to  the  end  of  a  jDencil. 

In  older  children  the  treatment  varies  according  to  the  acuteness  or 
chronicity  of  the  disease.  In  either  ease  it  is  important  to  keep  the  hair 
cut  closely  to  the  scalp  in  the  neighbourhood  of  the  patches.  The  disease 
is  most  infectious  in  its  earlier  stages,  and  becomes  much  less  liable  to  be 
communicated  when  undergoing  treatment.  Of  course  care  will  be  taken 
that  towels,  pillows,  etc.,  used  for  the  patient  are  not  shared  by  the  other 
childi-en.  As  an  additional  precaution  Dr.  E.  Liveing  recommends  that 
the  carbolised  glycerine,  pui-e  or  diluted  with  an  equal  proportion  of  gly- 
cerine, should  be  weU  rubbed  into  the  scalj)  every  morning. 

In  a  recent  case,  if  the  diseased  patch  be  of  small  extent,  it  should  be 
blistered  by  the  Hq.  epispasticus.  Afterwards,  when  the  sore  has  healed, 
the  oleate  "of  mercuiy  ointment  (five  per  cent.)  should  be  well  rubbed 
into  the  patch  every  night.  It  is  useful  to  vary  the  apphcation  every 
week  or  ten  days.  Therefore,  in  addition  to  the  preceding,  a  salve  com- 
posed of  sulphur  ointment  (half  an  ounce)  with  white  precipitate  (twenty 
grains)  may  be  used,  or  the  ointment '  recommended  by  ]\Ir.  Alder  Smith, 
made  by  adding  one  part  each  of  pui-e  carbohc  acid  and  unguentum  hych-ar- 
gyri  nitratis  to  four  parts  of  the  unguentum  sulphuris,  may  be  employed. 
A  favourite  remedy  in  recent  cases  is  the  preparation  known  as  "  Coster's 
jDaste,"  made  by  adding  two  drachms  of  iodine  to  one  ounce  of  the  colour- 
less oil  of  tar.*^  Mr.  Morant  Baker  prefers  to  substitute  creasote  for  the 
oil  of  tar.  The  apphcation  is  to  be  painted  thickly  on  the  patch  with  a 
camel's-hair  brush. 

If  imder  treatment  the  patches  become  very  sore,  so  that  the  rubbing 
in  of  the  ointments  causes  too  great  pain,  ]Mr.  Alder  Smith  recommends 
simply  smearing  the  surface  of  the  patch  with  the  carbohc  ointment  diu-- 
ing  the  day  and  poulticing  with  bread-and-water  every  night.  These 
measui-es  are  often  followed  by  a  rapid  cure.     The  penetration  of  the 

1  In  mixing  this  ointment  no  heat  is  to  he  applied.  The  two  salves  are  first  to  he 
amalgamated,  and  the  carholic  acid  is  then  to  be  ruhhed  in.  The  strength  of  this  ap- 
plication can  he  varied  according  to  the  age  of  the  child  by  increasing  the  proportion 
of  carbolic  acid  and  nitrate  of  mercury. 


THE   PARASITIC   DISEASES — TINEA   TONSURANS.  803 

remedy  into  tlie  liaii'-foUicles  is  aided  by  previous  removal  of  the  hair- 
stumps.  This  epilation  is  done  with  a  forcejDS  made  for  the  purpose. 
Care  must,  however,  be  taken  in  extracting  the  hair,  as  on  account  of  its 
brittleness  it  is  very  apt  to  break  ofi"  leaving  the  bulb  still  in  the  follicle. 
It  is  also  important  to  pick  or  wash  off  the  fine  crusts  of  scurf  which,  as 
long  as  they  remain,  are  greatly  in  the  way  of  efficient  treatment.  If  the 
scab  is  difficult  to  remove  it  should  be  well  greased  with  cold  cream  or 
saturated  with  ohve-oil,  and  poulticed.  It  then  becomes  quite  soft  and 
can  be  easily  picked  off. 

In  old-standing  cases  the  above  remedies  are  still  of  sei'vice,  and  careful 
epilation  should  be  practised.  Sometimes  the  long  duration  of  the  dis- 
order seems  to  be  due  to  ignorance  or  neglect ;  the  remedies  not  having 
been  applied  effectually,  or  care  not  having  been  taken  to  remove  the  scurf 
before  applying  the  salve.  The  energetic  use  of  oleate  of  mercury  oint- 
ment (five  per  cent.)  is  recommended  by  Mr.  Alder  Smith  as  a  useful 
remedy  even  in  chronic  cases.  After  careful  washing  of  the  head  the 
oleate,  freshly  made,  is  well  rubbed  into  the  whole  scalp  with  a  sponge 
mop.  In  the  use  of  this  application  it  is  well  to  refrain  from  charging  the 
mop  too  liberally  with  the  remedy,  lest  the  ointment  run  down  the  face 
and  neck.  At  night,  too,  a  linen  cap  should  be  worn  on  the  head ;  and  a 
thin  towel  is  often  necessary,  applied  as  a  turban,  to  prevent  irritation  of 
the  face  by  the  oleate.  Any  smearing  of  the  skin  elsewhere  than  on  the 
scalp  with  the  salve  wiU  produce  a  copious  eruption  of  small  pustules  and 
much  swelling.  Every  night  the  general  aj)plication  is  to  be  repeated  ; 
in  the  morning  the  inunction  is  to  be  limited  to  the  diseased  patches. 
While  this  plan  of  treatment  is  being  carried  out  the  head  must  be  washed 
only  once  a  fortnight ;  but  scabs  or  yellowish  incrustations  must  be  fre- 
quently removed  by  the  forceps.  If  the  oleate  set  up  inflammation  in  the 
patch  a  speedy  cure  is  usually  effected. 

The  beneficial  effects  observed  as  a  consequence  of  inflammation  set  up 
in  tlie  patch  has  led  to  the  employment  of  special  irritants  with  the  express 
view  of  producing  this  result.  Mr.  Alder  Smith,  who  has  devoted  much 
attention  to  this  method  of  treatment,  states  that  very  long-standing  cases 
can  sometimes  be  cured  by  this  means.  He  selects  a  small  patch  and  ap- 
plies to  it  croton-oil  in  moderate  quantity  with  a  small  stiff  camel's-hair 
brush.  After  a  few  hours  he  applies  a  poultice  and  keeps  it  on  the  head 
all  night.  If  severe  inflammation  has  not  ensued  by  the  next  day  the 
process  is  repeated,  and  sometimes  three  or  four  applications  may  be 
needed.  The  object  is  to  set  up  artificial  "kerion,"  i.e.,  to  produce  a 
swollen,  boggy,  freely-discharging  surface  from  inflammatory  swelling  and 
effusion  in  the  tissues  around  the  follicles.  When  kerion  is  jDroduced  no 
more  croton-oil  need  be  applied,  but  the  part  must  be  frequently  fomented 
with  warm  water.  After  a  few  days  the  stumpy  hairs  become  loose  and 
fall  out,  and  when  the  inflammation  has  subsided  a  smooth,  shining, 
slightly-raised  red  surface  is  left  "  utterly  destitute  of  all  hairs  and  stumps 
and  practically  well."  Eventually,  the  spot  becomes  again  covered  by  new 
health}^  hairs. 

This  plan  of  treatment  is  only  admissible  in  the  older  children,  and 
the  aj)plication  should  be  confined  to  a  limited  sui-face  if  the  patch  is  a 
large  one.  While  in  progress  the  carbolic  glycerine  or  oleate  should  still 
be  applied  to  other  parts  of  the  scalp.  By  this  means  Mr.  Alder  Smith 
states  that  he  has  had  successful  results  in  apparently  incurable  cases, 
and  has  never  seen  any  internal  irritation  or  erysipelas  set  up  by  the  use 
of  this  powerful  irritant. 


804  DISEASE   IN   CHILDEEIST. 

In  obstinate  cases  of  ringworm  of  the  scalp  constitutional  treatment  is 
also  required.  Often  the  patients  are  ansemic,  scrofulous,  or  ill-nourished 
subjects,  and  cod-liver  oil  and  tonics  will  be  of  service  in  improving  their 
general  health. 

Pdngworm  of  the  body  {tinea  circinata)  is  quickly  cured  by  the  applica- 
tion of  a  strong  irritant.  I  am  in  the  habit  of  painting  the  ring  lightly 
with  glacial  acetic  acid.  This  application  causes  some  smarting  for  a  short 
time,  but  usually  cures  the  disorder  at  once.  Sometimes  a  second  appli- 
cation to  parts  of  the  ring  is  required  after  five  or  six  days.  Other  appU- 
cations  which  may  be  used  are  the  strong  tincture  of  iodine,  and  a  solu- 
tion of  nitrate  of  silver  (  3  j.  to  the  ounce). 


TINEA    FAVOSA. 

Tinea  favosa,  or  favus,  is  much  less  common  in  England  than  the  pre- 
ceding. Like  it  it  is  a  contagious  disease,  and  is  most  frequently  seen  in 
scrofulous  or  neglected  and  badly-fed  children.  It  is  said  to  be  common 
in  some  countries  in  mice  and  rats,  and  instances  have  been  known  in 
which  the  disease  has  been  conveyed  from  these  animals  to  the  children  of 
the  family. 

Favus  is  due  to  the  presence  of  a  cryptogam — the  achorion  Schoenleinii. 
The  mycelium  and  spores  of  this  fungus  may  be  seen  without  difficulty  if 
a  portion  of  the  crust  be  put  under  the  microscope,  moistened  with  a  drop 
of  liq.  potassse. 

Symptoms. — Like  tinea  tonsurans,  favus  may  occur  on  any  part  of  the 
body,  but  is  usually  met  with  on  the  head.  It  begins  in  small  scaly 
patches  which  cause  much  itching.  In  this  early  stage  the  disease  bears  a 
close  resemblance  to  the  ordinary  ringworm,  especiaUy  as  the  hairs  grow- 
ing on  the  diseased  spot  quickly  lose  their  lustre  and  get  dull  in  colour. 
They  do  not,  however,  as  in  ringworm,  become  brittle,  so  that  there  is  no 
difficulty  in  pulling  them  out  with  the  forceps. 

After  a  time  small  yellow  crusts  of  about  the  size  of  a  pin's  head  appear 
on  the  patch  round  the  hairs.  These  crusts  are  at  first  convex,  but  after- 
wards as  they  enlarge  become  cup-shaped.  They  are  of  a  sulphur-yellow 
colour,  and  vary  from  a  split  pea  to  a  mass  of  the  diameter  of  half  an  inch. 
Usually  one  or  two  hairs  pass  through  the  centre.  At  first  the  favus  crusts 
are  placed  singly,  but  they  may  afterwards  become  confluent,  so  as  to  form 
irregular-shaped  masses,  more  or  less  extensive,  and  without  the  character- 
istic cup-shaped  depression.  The  smell  of  the  head  covered  by  the  crusts 
is  very  unpleasant  and  somewhat  resembles  that  of  mice.  On  the  removal 
of  a  favus  crust  a  depression  is  seen  which  is  red  and  may  be  ulcerated. 
This,  after  a  few  days,  disappears  and  the  surface  becomes  again  covered  by 
a  new  crop  of  cup-shaped  crusts.  •  When  the  crusts  become  detached  and 
fall  off  spontaneously  the  skin  is  merely  seen  to  be  stained  of  a  dark  red 
or  violet  colour.  As  the  disease  goes  on  the  hairs  lose  their  natural  tint, 
and  grow  loose  in  their  sockets  so  as  to  be  pulled  out  with  ease.  Their 
shafts  are  found  on  inspection  to  be  irregular  in  their  diameter  at  differ- 
ent points,  and  their  roots  are  atrophied.  They  become  fewer  in  number, 
and  if  the  disease  persists  may  disappear  altogether,  leaving  the  part  com- 
pletely bald. 

On  the  body  favus,  like  tinea  tonsurans,  forms  rings,  but  these  always 
remain  small,  seldom  exceeding  half  an  inch  in  diameter,  and  have  not  the 
characteristics  of  tinea  circinata.     In  other  respects  they  bear  a  close  re- 


THE   PAEASITIC   DISEASES — TINEA   FAVOSA.  805 

semblance  to  that  disease.  Afterwards,  however,  the  characteristic  crusts 
make  their  appearance  at  the  edges  and  on  the  surface  of  the  rings. 

Diagnosis. — When  the  disease  is  well  developed  on  the  scalp,  the  cup- 
shaped  crusts,  and  their  sulphur-yellow  colour  are  very  characteristic.  It 
is  in  the  early  stage  before  the  crusts  appear,  and  in  the  later  stage  when 
the  crusts  have  lost  their  peculiar  features,  that  the  disease  is  liable  to  be 
mistaken.  In  the  early  stage  the  round,  itching,  scaly  patches  closely 
resemble  common  ringworm,  but  a  distinction  is  supplied  by  the  want 
of  brittleness  of  the  hairs  in  favus.  In  this  disease  the  hairs  can  be  pulled 
out  of  their  follicles  with  ease,  while  in  tinea  tonsurans,  if  an  attempt  be 
made  to  extract  the  hair,  it  almost  invariably  snaps  short  off  close  to  the 
scalp.  In  the  later  stage  when  the  crusts  have  lost  their  distinctive  char- 
acter, especially  if,  as  often  happens,  they  have  become  complicated  with  a 
secondary  eczematous  eruption,  the  diagnosis  is  again  less  obvious,  but  the 
history  of  the  case,  and  a  careful  microscopic  examination  of  the  crusts, 
which  reveals  the  mycelium  and  spores  of  the  cryptogam,  wiU  indicate  the 
nature  of  the  case. 

Treatment. — The  crusts  must  be  removed  by  saturating  them  with  olive- 
oil,  and  then  poulticing,  or  by  constantly  applying  a  strong  sulphurous 
acid  lotion  under  a  cap  of  oiled  silk.  When  the  scalj)  is  quite  denuded  of 
crusts  and  scabs  the  hair  must  be  cut  close  to  the  skull,  and  steps  can 
then  be  taken  to  remove  all  the  hairs  from  the  diseased  surface.  This  is  a 
work  requiring  much  time,  trouble,  and  patience  ;  for  each  hair  must  be 
carefully  extracted  by  the  forceps,  taking  care  to  pull  in  the  direction  in 
which  the  hair  is  growing.  When  this  has  been  done,  the  special  remedy 
must  be  weU  rubbed  into  the  scalp.  Any  of  the  applications  recommended 
for  tinea  tonsurans  may  be  made  use  of,  but  one  of  the  most  effectual  is 
the  oleate  of  mercury  ointment  (five  per  cent.).  This  must  be  used  care- 
fully and  with  precaution  that  the  ointment  does  not  run  over  the  face. 

If  the  child  be  badly  nourished  or  ansemic,  sti-eugthening  medicines 
and  good  nourishing  food  will  be  of  service  in  aiding  his  recovery. 


CHAPTER  YI. 

SCLEREMA. 

Sca^EKEMA,  a  disease  which  consists  in  a  hardening  of  the  cutaneous  cellular 
tissue  sometimes  met  with  in  young  infants,  is  rai'ely  observed  in  England, 
but  aj^pears  to  be  less  uncommon  on  the  continent  of  Eui'ope.  The  affec- 
tion was  first  completely  described  by  Underwood  and  Denmau,  Shortly 
afterwards  Andiy  of  Paris  applied  Underwood's  description  to  a  totally 
different  lesion.  This  observer  had  frequently  noticed  at  the  Hospice  des 
Enfants-Trouves  of  Paris  a  condition  in  which  the  sui'face  of  the  body  be- 
comes indui'ated  as  a  consequence  of  subcutaneous  oedema.  This  disorder 
answered  in  many  respects  to  Underwood's  description,  so  that  by  a  not 
unnatural  confusion  Andi-y  adopted  Underwood's  term  for  his  own  account 
of  cedema  of  the  new-born  infant.  After  his  time  the  eiTor,  thus  begun, 
was  perpetuated  by  successive  -wiiters  until  PaiTot,  to  whose  labours  the 
pathology  of  infantile  disease  is  so  much  indebted,  showed  clearly  in  his 
work  on  "  Athrepsie  "  that  two  very  different  conditions  had  been  hitherto 
confounded  under  the  same  title.  In  the  present  chapter  the  true  sclerema 
will  be  first  described  ;  afterwards  a  short  account  will  be  given  of  "  oedema 
of  the  new-born  infant." 

TRUE  SCLEREMA. 

True  sclerema  (induration  of  the  cutaneous  cellular  tissue)  is  confined 
to  new-born  infants.  This  lesion  is  not  to  be  confounded  mth  the  sclero- 
derma which  attacks  older  children  and  adults.  It  occurs  only,  according 
to  Parrot,  in  feeble  infants  and  those  wasted  by  bad  feeding  and  luiwhole- 
some  conditions  generally.  According  to  Underwood  it  appears  as  a  fea- 
ture of  the  last  stage  of  atrophy  from  digestive  derangements. 

Morbid  Artatomy. — The  lesion  consists  in  a  curiously  condensed  state 
of  the  skin.  This  tissue  is  thinned  as  if  fi'om  compression  of  the  several 
layers.  The  rete  IMalpighii  and  corium  have  sensibly  lost  thickness,  and 
the  coils  of  the  former  layer  can  hardly  be  detected,  so  intimately  are  they 
amalgamated  into  a  compact  mass.  In  the  adipose  layer  the  fat-lobules 
are  atrophied ;  their  globules  are  wasted;  and  the  connective-tissue  bands 
are  more  numerous  and  thicker  than  in  the  normal  state.  According  to 
Underwood,  the  induration  of  the  cellular  tissue  may  reach  the  sheaths  of 
the  muscles  and  even  affect  theii'  fibres.  There  is  never  any  subcutaneous 
oedema  in  the  true  disease.  The  blood-vessels,  especially  those  of  the  pap- 
illse,  are  so  narrowed  that  then*  lumen  is  obhterated.  These  pathological 
changes  form  a  veiy  distinct  condition — different  on  the  one  hand  fi-om 
oedema  of  the  new-bom,  and  on  the  other  from  scleroderma  of  older  chil- 
dren and  adults.  They  are  the  consequence,  according  to  Parrot,  of  de- 
siccation of  the  tegumentary  tissues  owing  to  the  draining  away  of  fluid  by 
the  copious  wateiy  discharges  from  the  bowels.     There  must,  however,  be 


SCLEEEMA — MORBID   ANATOMY — SYMPTOMS.  807 

some  other  cause  for  the  pathological  change,  for  in  this  country  it  is  com- 
mon enough  to  find  young  infants  reduced  by  bad  feeding  and  profuse 
watery  diai-rhcea  to  a  state  of  extreme  emaciation  ;  but  sclerema  is  a  lesion 
so  rare  that  when  discovered  it  is  regarded  as  a  clinical  curiosity. 

A  form  of  sclerema  called  adipose  sclerema  is  sometimes  met  with. 
This  is  different  pathologically  from  the  preceding.  It  is  due  to  a  solidifi- 
cation during  life  of  the  subcutaneous  fat.  According  to  Dr.  Langer  the 
melting  point  of  infant's  fat  is  113°  Fahr.,  or  a  higher  point  than  the 
temperature  of  the  body  ;  while  adult  fat  becomes  perfectly  fluid  at  a  tem- 
perature of  96.8°  Fahr.  Hence,  in  the  healthy  child  during  life,  a  large 
proportion  of  its  fat  is  not  quite  fluid  but  merely  soft.  If,  from  any  reason, 
such  as  collapse,  or  the  rapid  withdrawal  of  heat  which  sometimes  occurs  in 
young  infants  as  a  consequence  of  depressing  illness,  the  temperature  of 
the  body  falls  to  89.6°,  this  degree  of  coohng,  according  to  Dr.  Langer,  is 
sufficient  completely  to  solidify  all  the  fat  in  the  panniculus  adiposus. 

Symptoms. — The  more  special  symptoms  of  sclerema  are  preceded  by 
great  impairment  of  nutrition  and  rapid  wasting.  The  induration  begins 
to  be  noticed  at  the  end  of  the  first  week  of  life,  or  on  the  ninth  or  tenth 
day,  or  in  some  cases  in  the  course  of  the  second  month.  According  to 
some  writers  it  is  esj^ecially  in  infants  born  fairly  healthy  and  robust,  and 
whose  nutrition  has  become  I'apidly  impaired  that  the  cutaneous  symptom 
is  most  likely  to  occur. 

The  induration  generally  begins  in  the  lower  limbs  and  spreads  thence 
to  the  loins,  the  back,  the  chest,  and  eventually  to  the  whole  body,  face 
included.  In  some  cases  the  face  is  said  to  be  attacked  early,  and  the  in- 
duration to  spread  from  this  part  to  the  body.  The  affected  skin,  com- 
pletely losing  its  natural  softness  and  suppleness,  becomes  hard  and  un- 
yielding, and  pressure  with  the  finger  meets  a  resistance  like  that  of  horn 
or  hardened  leather.  The  folds  and  lines  of  the  skin  disappear,  and  partly 
from  rigidity,  partly  from  its  close  connection  with  the  underlying  tissues, 
it  can  no  longer  be  pinched  up  between  the  finger  and  thumb. 

When  the  whole  body  is  thus  affected  the  induration  prevents  any 
bending  of  the  joints,  so  that  the  limbs  are  sti-etched  stiffly  out,  and  it  is 
even  said  that  the  body  may  be  supported  in  a  horizontal  position  in  the 
air  by  a  hand  placed  under  the  loins.  The  rigidity  of  the  face,  especially 
of  the  lips  and  cheeks,  makes  sucking  impossible,  although  the  induration 
of  this  part  is  usually  less  advanced  than  that  of  other  regions  of  the  body. 
But  for  this,  and  for  the  little  feeble  respiratory  movement  of  the  abdomen 
and  chest,  the  infant  might  be  thought  to  be  dead.  Indeed,  the  tightly- 
compressed  lips,  the  closed  eyes,  the  mask-like  face,  the  immobility  of  the 
frame,  and  the  peculiar  coldness  of  the  surface,  resemble  death  more 
nearly  than  life. 

The  lowness  of  the  temperature  is  one  of  the  striking  features  of  this 
condition.  The  diminution  of  heat  of  the  skin  gives  a  marked  sensation 
of  coldness  to  the  hand,  and  even  in  the  rectum  the  temperature  may  fall 
far  below  the  normal  level.  The  body  is  not  only  cold,  but  seems  incapa- 
ble of  being  warmed  ;  and  even  the  occurrence  of  pneumonia  has  no  ap- 
preciable eflect  in  raising  the  temperature.  The  pulse  and  respiration  faU 
in  frequency.  The  former  may  be  as  low  as  sixty  in  the  minute,  the  latter 
fourteen.  The  respiratory  movements  are  hampered  and  feeble,  and  the 
cry  is  weak  and  almost  inaudible. 

The  course  of  the  disease  is  very  rapid.  The  induration  proceeds 
apace.  By  the  third  day,  according  to  Underwood,  the  skin  has  become 
intimately  adherent  to  the  tissues  beneath.     By  the  fourth  the  induration 


808  DISEASE   IX    CHILDEEX. 

has  become  general  over  the  body.     The  child  usually  dies  on  the  seventh 
day  or  soon  afterwards. 

(EDEMA  OP  NEW-BORN  CHILDREN. 

(Edema  of  new-born  children  is  also  a  very  rare  disease  in  this  coun- 
try. The  subcutaneous  tissue  is  infiltrated  ^vith  yellowish  serosity  which 
permeates  between  the  adipose  lobules,  but  never  passes  between  the 
muscles  or  sinks  below  the  level  of  the  subcutaneous  tissue.  The  fat  is 
converted  into  a  yellowish  brown  mass.  In  some  cases  there  is  congenital 
atelectasis. 

Symptoms. — The  disease  begins,  according  to  Valleix,  before  the  third 
day  of  life,  and  the  infants  affected  are  almost  always  prematurely  born  or 
feeble.  At  first  the  child  is  noticed  to  be  drowsy,  and  its  skin  is  then 
found  to  be  livid  and  very  cold  to  the  touch.  The  oedema  is  first  noticed 
in  the  feet  and  thence  spreads  upwards  to  the  thighs.  The  hands  are  next 
attacked,  and  later  the  oedema  appears  in  the  genitals  and  the  back.  There 
are,  however,  exceptions  to  this  order.  Valleix  states  that  he  has  known 
the  oedema  to  appear  first  in  the  cheek  ;  and  sometimes  the  hands  begin 
to  swell  directly  after  the  feet  have  been  attacked.  The  swelling  is  usually 
greater  on  one  side  than  on  the  other,  and  tends  always  to  sink  to  that  on 
which  the  infant  is  lying.  The  aifected  parts  pit  with  difficulty  on  press- 
ure, but  are  swollen,  and  feel  doughy  and  hard.  The  skin  at  first  has  a 
purple  colour,  especially  at  the  extremities,  and  before  death  may  have  a 
jaundiced  hue.  It  does  not  become  adherent  to  the  parts  beneath  as  in 
the  case  of  sclerema,  and  there  is  not  the  same  stifihess  of  the  joints.  The 
temperatru'e  is  low  and  may  fall  to  86°.  It  is  httle  raised  by  the  external 
application  of  warmth  to  the  body.  The  child  lies  in  a  drowsy  apathetic 
state,  and  scarcely  attempts  to  cry.  The  pulse  is  small  and  very  feeble  ; 
the  breathing  slow  and  interrupted ;  convulsions  may  come  on,  and  the 
prostration  may  be  increased  by  a  watery  diarrhoea.  Death  may  be  hast- 
ened by  intercurrent  attacks  of  bronchitis,  jDueumonia,  collapse  of  the 
Irmg,  gastric  or  intestinal  catarrh,  etc.  In  some  of  the  cases  parenchyma- 
tous nephritis  and  albuminuria  have  been  observed. 

Diagnosis. — The  two  diseases,  sclerema  and  cedemaof  the  new-bom,  are 
very  dissimilar,  although  they  appear  to  be  produced  by  much  the  same 
conditions,  and  certain  symptoms  are  common  to  both.  In  each  case  we 
find  a  lowering  of  the  temperatui'e,  a  fall  in  the  pulse  and  respiration,  and 
a  rigidity  of  the  surface  of  the  body.  In  each  case  the  weakness  is  pro- 
found ;  and  the  infant  hes  motionless,  refuses  to  suck,  and  more  neai'ly 
resembles  a  dead  child  than  a  living  one.  There  are,  however,  important 
difi^erences  in  the  two  diseases.  In  sclerema  the  skin  is  tense  and  hard, 
and  adheres  firmly  to  the  tissues  beneath  it ;  the  joints  are  extended  and 
stiff,  and  the  whole  body  is  rigid  as  if  petrified  or  frozen.  The  fii-mness 
and  rigidity  increase  day  by  day,  and  death  occui's  at  the  end  of  the  fii'st 
or  the  beginning  of  the  second  week. 

In  oedema  the  parts  affected  are  firm  and  Swollen,  but  can  be  made  to 
pit  on  deep  pressure.  The  swelling  is  partial  and  is  most  marked  on  the 
side  upon  which  the  child  is  Ipng.  The  skin  can  be  moved  over  the  parts 
beneath  it  ;  and  the  stiffness  of  the  joints  is  but  little  pronounced,  never 
prevailing,  as  in  sclerema,  to  a  sufficient  degree  to  resist  the  force  of 
gi-avit\\  The  disease,  also,  is  of  longer  diu'ation  than  is  the  case  with 
sclerema,  and  although  very  dangerous  on  account  of  the  weakness  of  the 


SCLEEEMA— (EDEMA   OF  NEW-BORN   CHILDREN.  809 

child,  is  not  invariably  fatal.  The  two  diseases  may  exist  together,  or 
sclerema  may  succeed  to  oedema,  as  in  a  case  reported  by  Parrot. 

Treatment. — In  cases  of  tiiie  sclerema  Httle  can  be  done.  On  account 
of  the  impossibility  of  sucking,  the  infant  should  be  fed  with  white  wine 
whey  by  means  of  the  syi-inge  feeder  (see  page  15).  By  this  means  a 
sufficient  quantity  of  food  can  be  introduced  at  intervals  into  the  back  of 
the  throat  when  it  is  readily  swallowed.  In  order  to  maintain  the  warmth 
of  the  body,  the  child  should  be  wrapped  in  cotton-wool,  and  should  be 
surrounded  with  hot  water-bottles. 

In  the  oedema  of  new-bom  infants  the  child,  if  he  cannot  suck,  may  be 
fed  with  the  syi-inge  as  directed  above.  He  should  take  white  wine  whey, 
milk  and  barley-water,  and  other  varieties  of  food  suitable  to  this  period 
of  life  (see  page  603).  Warmth  must  be  maintained  as  in  the  former  case, 
and  gentle  frictions  to  the  surface  of  the  body  are  of  service  in  helping  to 
disperse  the  oedema. 


INDEX. 


Abdomen,  large,  in  infancy,  13 

large,  in  rickets,  141 

retracted,  in  tubercular  meningitis,  13, 
359 
Abdominal  muscles,  rheumatism  of,  159 

wall  in  tubercular  meningitis,  358 
Abscesses  in  scarlet  fever,  40 

in  small- pox,  59 

subcutaneous,  in  scrofula,  177 
Aconite  in  treatment  of  quinsy,  588 
Acorion  Schoenleinii,  804 
Acorn  coffee  in  treatment  of  scrofula,  188 
Acute  rickets,  143 
Adenia  (see  Lymphadenoma),  330 
^gophony  as  a  sign  of  effusion,  405 
Aglobulosis,  331 
Ague,  147 

auEemia  in,  149 

cachexia  of,  149 

causation  of,  147 

cold  stage  of,  148 

congestion  of  liver  in,  148 
treatment  of,  151 

diagnosis  of,  149 

diarrhoea  in,  149 

duration  of,  149 

hot  stage  of,  148 

in  cachectic  children,  149 

morbid  anatomy  of,  147 

oedema  in,  149 

prognosis  in,  150 

quinine,  hypodermic  injection  of,  in, 
151 

splenic  enlargement  in,  148 

sweating  stage  of,  148 

symptoms  of,  148 

temperature  in,  148,  149 

treatment  of,  151 

types  of,  148 

urine  in,  149 
Albuminous  retinitis   in   chronic  Bright's 

disease,  755 
Albuminuria  a  serious  symptom  in  congen- 
ital heart  disease,  543 

from  embolism  of  kidney,  158 

in  acute  tuberculosis,  195 

in  ague,  149 

in  Bright's  disease,  acute,  39 
chronic,  755 


Albuminuria  in  diphtheria,  95 

in  infantile  tetanus,  310 

in  measles,  34 

in  membranous  croup,  89,  414 

in  pneumonia,  croupous,  436 

in  scurvy,  357 

in  stridulous  laryngitis,  413 

in  thrush,  bad  cases  of,  574 

intermittent,  74G 

scarlatinous,  39 

treatment  of,  46 
Air-passages,  diseases  of,  399 

foreign  body  in  (see  Foreign  Body  in 
Air-tubes).  536 

obstruction  of,  519 
Alcohol,  value  of.  18 
Alopecia  areata,  781 

treatment  of,  781 
Alum  in  whooping-cough,  185 
Amyl,  nitrite  of,  in  convulsions,  385 

in  epilepsy,  393 
Amyloid  degeneration  of  organs  in  empy- 
ema, 450 

in  inherited  syphilis,  311 

in  pulmonary  cirrhosis,  477 

liver  (see  Liver,  the  Amyloid),  731 
Anemia,  339 

aperients  in  treatment  of,  334 

arsenic  in  treatment  of,  335 
■  breathlessness  in,  233 

causation  of,  330 

cold  water  packing  in  treatment  of, 
335 

complexion  in,  333 

diagnosis  of,  333 

diet  in,  334 

epistaxis  in,  333 

headache  in,  333 

idiopathic,  333 

in  ague,  149 

in  amyloid  liver,  733 

in  chronic  Bright's  disease,  755 

in  valvular  disease  of  heart,  547 

in  empyema,  447 

in  fibroid  induration  of  lung,  477 

in  gastric  catarrh,  331,  611 

in  gastro-intestinal  hemorrhage,  656 

in  hgemophilia,  344 

in  hcemorrhagic  purpura,  350 


812 


INDEX. 


Anaemia  in  hypertrophied  spleen,  238 

in  inherited  syphilis,  310,  231 

in  leacocythemia,  217 

in  lymphadenoma,  224 

iron  in  treatment  of,  234 

morbid  anatomy  of,  231 

murmurs  in,  233 

palpitation  in,  232 

petechiae  in,  233 

prognosis  in,  234 

readily  produced  in  the  child,  229 

symptoms  of,  232 

treatment  of,  234 
Aneurism  in  eax'ly  life,  cause  of,  323,  549 

rupture  of,  on  brain,  322 
case  of,  327 
Angina  (see  Pharyngitis),  576 

scarlatinous,  35,  37 
Anthelmintics,  712 
Antimony  in  treatment  of  bronchitis,  488 

of  inflammatory  diarrhoea,  639 
Antiseptic  sprays  in  diphtheria,  104 

in  gangrene  of  lung,  500 

in  pulmonary  phthisis,  518 

in  whoopiug-cough,  126 
Aorta  and  pulmonary  artery,  transposition 
of,  536 

duration  of  life  in,  541 
Aperients,  abuse  of,  19 

for  habitual  constipation,  621 
Aperients,  value  of,  in  treatment  of  anse- 
mia,  234 

of  acute  Bright's  disease,  46 

of  chronic  Bright's  disease,  761 

of  quinsy,  589 

of  urasmia,  46 

of  valvular  disease  of  heart,  553 
Aphasia  in  early  life,  significance  of,  263 
Aphonia,  hysterical,  409 
Apoplexy,   cerebral  (see  Cerebral  Hsemor- 

rhage),  322 
Aromatics,  value  of,  in  artificial  feeding, 

605 
Arsenic  as  a  prophylactic  in  scarlet  fever, 
43 

in  ague,  152 

in  ansemia,  235 

in  chorea,  305 

in  lymphadenoma,  227 

in  pemphigus,  780 

tolerance  of  children  for,  19,  306 
Artificial  feeding  of  children,  various  foods 

for,  604,  606 
Artificial  feeding  of  infants,  603 

common  cause  of  failure  in,  606 

method  of  conducting,  603 

necessity  of  vigilance  in,  608 

preparation  of  milk  for,  604,  606 

value  of  milk  in,  596 
Artificial  human  milk.  606 
Ascaris  lumbricoides,  705 

description  of,  705 

migrations  of,  706 

symptoms  of,  709 

treatment  of,  713 
Ascites,  700 


Ascites,  causation  of,  700 

diagnosis  of,  702 

fluctuation  in,  701 

in  acute  peritonitis,  687 

in  ansemia,  232 

in  atrophic  cirrhosis  of  liver,  701,  738 

in  congenital  heart  disease,  539 

in  tubercular  peritonitis,  695 

prognosis  in,  703 

symptoms  of,  700 

treatment  of,  704 
Asphyxia,  local,  167 
Asthenic  measles,  24 
Asthma,  bronchial,  520 

causation  of,  520 

diagnosis  of,  521 

symptoms  of,  581 

treatment  of,  524 
Asthmatic  attacks  from  enlarged  bronchial 

glands,  182,  522 
Atelectasis,  congenital,  461 

artificial  respiration  in,  464 

causation  of,  461 

diagnosis  of,  463 

diet  in,  464 

drowsiness  in,  462 

emetics  in  treatment  of,  464 

hot  bath  in  treatment  of,  464 

lividity  in,  462 

morbid  anatomy  of,  461 

physical  signs  of,  463 

prognosis  in,  463 

respiratory  movements  in,  463 

stimulants  in  treatment  of,  464 

symptoms  of,  463 

temperature  in,  463 

treatment  of,  463 

w^armth,  importance  of,  in,  464 
Atelectasis,  post-natal,  465 

causation  of,  465 

convulsions  in,  437 

diagnosis  of,  469 

diet  in,  473 

in  infants,  467 

in  older  children,  468 

lividity  in,  467 

morbid  anatomy  of,  466 

physical  signs  of,  467 

prognosis  in,  471 

respirations  in,  467 

sudden  death  from,  467 

symptoms  of,  467 

temperature  in,  467 

treatment  of,  471 
Atrophy  in  infantile  syphilis,  211 

infantile  (see  Infantile  Atrophy),  596 
Atrophy  of  muscle  in  acute  infantile  spinal 
paralysis,  375 

in  chorea,  303 

in  hemorrhage  into  cord,  377 

in  pseudo-hypertrophio  paralysis,  386 

in  rickets,  134 
Atrophy  of  third  nerve  from  pressure,  336 

of  tissues  in  thrush.  573 

period  of,  in  infantile  spinal  paralysis, 
375 


INDEX. 


813 


Atrophy,    progressive    muscular,   rare    in 

childhood,  387 
Atropia  in  treatment  of  whooping-cough, 

124 
Attitude,  clinical  value  of,  8 
Attitudes  in  spinal  caries,  178 
Auscultation  of  chest,  403 
of  skull  in  rickets,  138 

Bacillus  of  whooping-cough,  115 

the  tubercle,  191,  506,  510 
Back,  pain  in,  in  caries  of  spine,  178 

in  cerebro- spinal  fever,  69 

in  small-pox,  56 
Back,  stiffness  of,  in  caries  of  spine,  178 
Backward  children,  395 
Bacteria  in  umbilical  phlebitis,  71 7 
Balsam   of    Peru    as   an    application  for 

scabies,  799 
Barley-water  in  the  hand-feeding   of   in- 
fants, 604 
Bath,  the  cold,  16 

the  hot,  16 

the  mustard,  16 
Baths  for  eczema,  793 

the  therapeutic  value  of,  16 
Belladonna  rash,  783 

tolerance  of,  in  childhood,  19 
Bile-ducts,  malformation  of,  716 
Bilharzia  hfematobia,  747 
Bladder,  atony  of,  in  enteric  fever,  71 

stone  in,  symptoms  of,  767 

tuberculosis  of,  193 
diagnosis  of,  199 
symptoms  of,  197 
Blindness  in  cerebro-spinal  fever,  71 
Blood,  clotting  of,  in  heart,  98,  550 

extravasations  of,  in  scurvy,  254 

in  ansemia,  229,  232 

in  leucocythemia,  217 

in  lymphadenoma,  222 

in  purpura,  248 

in  stools  (see  Melsena) 

poisoning  in  diphtheria,  95 

vomiting  of  (see  Hsematemesis) 
Blotches,  purpuric,  in  cerebro- spinal  fever. 
69,  70 

in  lymphadenoma,  224 

in  purpura,  248 

in  scurvy,  256 

in  spontaneous  gangrene,  168 
Bone,    arrest   of   growth   of,    in   infantile 
spinal  paralysis,  373 

in  rickets,  140 
Bones,  perverted  ossification  of,  in  rickets, 
132 

scrofulous  disease  of,  178 

syphilitic  disease  of,  206 
age  most  liable  to,  208 
Bothriocephalus  latus,  707 
Bowel,  perforation  of,  in  enteric  fever,  82 

treatment  of,  87 
Bowel,  prolapse  of,  from  straining  at  stool, 

619 
Bowels,  obstruction  of,  causes  of,  668 
Bowels,  ulceration  of,  660 


Bowels,  aperients  in,  danger  of,  664 

astringent  injections  in  treatment  of, 
667 

constipation  in,  661 

diagnosis  of,  664 

diarrhoea  in,  663 

diet  in,  666 

hseraorrhage  from,  662 

malted  bread  in  treatment  of,  666 

morbid  anatomy  of,  660 

nutrition  in,  662 

prognosis  in,  665 

raw  meat  treatment  of,  666 

stools  in,  662 

symptoms  of,  661 

temperature  in,  662 

treatment  of,  666 
Brain,  congestion  of,  316 

causation  of,  316 

connection  of,  with  convulsions,  817 

diagnosis  of,  319 

morbid  anatomy  of,  317 

prognosis  in,  320 

stupor  in, 318 

symptoms  of,  318 

temperature  in,  319 

treatment  of,  321 
Brain,    hsemorrhage    into   (see     Cerebral 

Hsemorrhage),  322 
Brain,  tumour  of  (see  Cerebral  Tumour), 

330 
Breast-milk,  analysis  of,  597 
Breath,  offensive,  in  cases  of  constipation, 
619 

of  fibroid  induration  of  lung,  477 

of  gangrene  of  lung,  499 

of  gangrenuos  stomatitis,  568 

of  ulcerative  stomatitis,  565 
Breathing,  amphoric,  value  of,  404 

cavernous,  value  of,  404 

Cheyne-Stokes  type  of,  264 

hollow,  in  cases  of  enlarged  bronchial 
glands,  182 

hollow,   in  cases  of   enlarged  tonsils, 
588 

hollow,  value  of,  404 

irregular  in  tubercular  meningitis,  359 
Breathing,     stertorous,     in    membranous 
croup,  95 

in  oedema  of  glottis,  408 

in  retro-pharyngeal  abscess,  592 

in  scald  of  larynx,  407 

in  stridulous  laryngitis,  412 

in  suppuration  about  larynx,  420 

in  tubercular  laryngitis,  416 

in  warty  growths  on  larynx,  417 
Breathlessness  (see  Dyspnoea) 

in  aiiEemia,  232 

in  heart  disease,  547 
Breath-sounds,  conduction  of,   by   chest- 
wall,  404 

suppressed  from  impaction  of  foreign 
body  in  air-tubes,  528 

weak,  clinical  value  of,  404 
Bright's  disease,  acute,  39 

convulsions  in,  39 


814 


INDEX. 


Bright's  disease,  acute,  symptoms  of,  39 

treatmeat  of,  46 

urine  in,  39 
Bright's  disease,  ch.ronic,  752 

ansemia  in.  755 

causation  of,  753 

diagnosis  of,  759 

dropsy  in,  754 

morbid  anatomy  of,  758 

prognosis  in,  760 

symptoms  of,  754 

treatment  of,  760 
Bromide  salts  in  convulsions,  284 

in  epilepsy,  292 

in  laryngismus  stridulus,  273 

in  -whooping-cough,  125,  284 

rash,  293 
Bronchi,  acute  dilatation  of,  435,  439 

diagnosis  of,  441 
Bronchi,  chronic  dilatation  of,  474 

diagnosis  of,  514 
Bronchial  glands,  enlargement  of,  178 

asthmatic  attacks  in,  182,  533 

diagnosis  of,  185,  522 

dyspnoea  in,  182,  523 

earliest  sign  of,  183 

epistaxis  in,  181 

hoarseness  in,  183 

cedema  of  face  in,  181 

physical  signs  of,  182 

prognosis  in,  186 

signs  of  pressure  from,  181 

symptoms  of.  180 

terminations  of,  181 

treatment  of,  188 

venous  hum  in,  183 
Bronchiectasis,  acute,  435,  439 

chronic,  474 

phy.'iical  signs  of,  476 
Bronchitis,  acute,  481 

capillar}",  483 

causation  of,  481 

counter-irritation  in,  486 

diagnosis  of,  485 

expectorants  in  treatment  of,  487 

morbid  anatomy  of,  483 

physical  signs  of,  486 

prognosis  in,  486 

pulse  in,  484 

symptoms  of,  483 

temperature  in,  483 

treatment  of,  486 
Bronchitis,  chronic,  484 

symptoms  of,  484 

treatment  of,  489 
Bronchitis,  tuberculous,  196 

diagnosis  of,  199 

Calabar  bean,  efPect  on  pulse  of,  313 
in  treatment  of  tetanus,  313 
of  tetany,  276 
Calculi,  renal.  T63 

Calculus  impacted  in  urethra  causing  re- 
tention, 748 
of  kidney  (see  Kidney,  Calculus  of), 
768 


Cancrum   oris   (see   Stomatitis,   Gangren- 
ous), 567 
Cardiac  dropsy,  547 

treatment  of,  553 
Caries  of  spine,  symptoms  of,  178 
Carpo-pedal   contractions   in   laryngismus 
stridulus,  269 

in  stridulous  laryngitis,  418 
Caseation  of  glands,  173 
Casein  of  cow's  milk,  597 

of  goat's  milk,  597 

of  human  milk,  597 
Castor-oil  in  treatment  of  dysentery,  651 

of  inflammatory  diarrhoea,  638 
Cataract,  congenital,  a  cause   of  nystag> 
mus,  261 

in  idiocy,  394 
CataiTh,  gastric  (see  Gastric  Catarrh),  601 

intestinal  (see  Diarrhoea),  624 

laryngeal  (see  Laryngitis),  406 

proneness  to,  in  rickets,  142 
in  scrofula,  176 
Catarrh,  pulmonary,  481 

causation  of.  481 

in  teething.  559 

recurring  attacks  of,  483 

symptoms  of,  482 

treatment  of,  486 
Catarrhal    pneumonia     (see     Pneumonia, 

Catan-hal),  434 
Cauterisation  in  treatment  of  gangrenous 

stomatitis,  570 
Cephalalgia  (i^ee  Headache) 
CerebeDar  tumour,  symptoms  of,  337 
Cerebral   arteries,  syphilitic  degeneration 
of,  211 

congestion  (see  Brain.  Congestion  of), 
316 

flush  in  tubercular  meningitis,  359 
Cerebral  hajmorrhage,  322 

causation  of,  322 

diagnosis  of,  328 

from  congestion  of  brain,  328 
from  meningitis.  325 
from  tumour  of  brain,  328 

from   aneurism  of  a  cerebral  artery, 
323 

in  a  case  of  purpura  hfemorrliagica,  251 

morbid  anatomy  of,  333 

prognosis  in,  329 

symptoms  of,  326 

temperature  in,  324 

treatment  of,  339 
Cerebral  embolism,  case  of,  548 

murmur  in  rickets,  138 

paralysis,  diagnosis  of,  377 

pneumonia,  364 

rheumatism,  156,  159 
Cerebral  sinuses,  thrombosis  of,  351,  650 

diagnosis  of,  353 

symptoms  of,  351 
Cerebral    symptoms    in    croupous    pneu- 
monia, 353,  364.  382 

without  cerebral  disease,  3 
Cerebral  tumour,  330 

convulsions  in,  332 


I 


INDEX. 


815 


Cerebral  tumour,  diagnosis  of,  337 

headache  in,  333 

loss  of  special  sense  in,  332 

morbid  anatomy  of,  330 

nature  of,  339 

optic  neuritis  in,  338 

paralysis  in,  332 

prognosis  in,  339 

symptoms  of,  331 

treatment  of,  339 

tremours  in,  333 

varieties  of,  331 

vomiting  in,  332 
Cerebritis  (see  Encephalitis),  351 
Oerebro-spinal  fever,  68 

blindness  from,  71 

causation  of,  68 

coma  in,  69 

convulsions  in,  70 

deafness  from.  71 

diagnosis  of,  72 

duration  of,  72 

eruption  in,  70 

hallucinations  in,  70 

in  infants,  72 

invasion  of,  69 

morbid  anatomy  of,  68 

paralysis  in,  70 

prognosis  of,  73 

pulse  in,  71 

pupils  in,  71 

retraction  of  head  in,  69  , 

rigidity  of  joints  in,  69 

symptoms  of,  69 

temperature  in,  70 

treatment  of,  73 

urine  in,  71 

vomiting  in,  70 
Chest,  auscultation  of,  403 

deficient  movement  of,  401 

distortion  of,  in  rickets,  139 

examination  of,  in  children,  399 

flattened,  the,  400 

infra -mammary  depression  of,  400 

movements  of,  in  respiration,  400 

pain  in,  from  foreign  body  in  air-tubes, 
528 

pain  in,  a  sign  of  spinal  caries,  178 

percussion  of,  402 

pigeon-breasted,  the,  400 

pterygoid,  the.  400 

resonance  of,  in  childhood,  402 
Chest,  retraction  of,  in  cirrhosis  of  lung, 
476 

in  inspiration,  400 

in  pleurisy,  450 
Chest,  shape  of,  in  chronic  bronchitis,  485 

in  chronic  tubercular  phthisis,  508 

in  congenital  heart  disease,  538 

in  emphysema,  493 
Chest-wall,    resistance   of,  to  percussion, 

403 
Chicken-pox,  diagnosis  of,  49 

duration  of,  49 

gangrenous,  49 

symptoms  of,  48 


Chicken-pox,  temperature  in,  48 

treatment  of,  50 
Childhood,  convalescence  in,  5 

definition  of,  5 

diathetic  tendencies  in,  4 

functional  disorders  in.  3 

proneness  to  antemia  in,  229 

sudden  death  in,  5,  270,  374 
Children,  forced  feeding  of,  15 
Chills,  susceptibility  to,  in  early  life,  4 

in  rickets,  142 

in  scrofula,  176 
Chloral,  in  treatment  of  chronic  albumin- 
uria, 46 

of  convulsions,  284 

of  laryngismus  stridulus,  273 
Chlorate  of  potash  in  ulcerative  stomati- 
tis, 566 
Chlorides,  urinary,  diminished  in  croupous 

pneumonia,  426 
Chorea,  299 

a  cause  of  valvular  disease  of  heart, 
544 

arsenic  in  treatment  of,  305 

atrophy   and   contraction   of    muscle 
after,  303 

causation  of.  299 

cold  douche  in  treatment  of,  305 

course  of,  304 

death  from,  304 

diagnosis  of,  304 

ether  sjjray  in  treatment  of,  306 

forced  feeding  in,  306 

heart  murmurs  in,  303 

massage  in  treatment  of,  306 

mental  state  in,  303 

muscular  weakness  in,  303 

pathology  of,  300 

prognosis  in,  304 

symptoms  of,  301 

temperature  in,  303 

treatment  of,  305 

urine  in,  303 
Circulation,  changes  in,  at  birth,  536 

foetal,  at  term,  535 

in  brain,  316 
Cirrhosis  of  liver  (see  Liver,  Cirrhosis  of), 
726 

of    lung   (see   Fibroid  Induration   of 
Lung),  473 
Club-foot  from  infantile  spinal  paralysis, 
376 

from  intra-uterine  convulsions,  277 
Cod-liver  oil,  precautions  in  giving,  18 
Cold  douche  in  treatment  of  chorea,  305 

of  malignant  scarlet  fever,  45 

of  rickets,  146 

of  scrofula,  188 

precautions  in  giving,  17 
Cold  sponging  in  enteric  fever,  86 

in  inflammatory  diarrhoea,  637 

in  laryngismus  stridulus,  272 
Cold  water  packing  for  anasmia,  235 
Colic,  cry  of,  9 

diagnosis  of,  674 

in  dysentery,  647 


816 


INDEX. 


Colic,  in  infants,  619 

in  purpura  hsemorrhagica,  249 

in  spontaneous  gangrene,  168 

renal,  766 

treatment  of  simple,  623 
Collapse,  general,  in  intussusception,  671 

of  lung  (see  Atelectasis),  461 
Colon,  severe  catarrh  of,  631 

character  of  stools  in,  635 

symptoms  of,  682 

treatment  of,  639 
Colour,  blue,  in  cyanosis,  cause  of,  538 
Coma  (see  Stupor) 
Complexion  in  amyloid  disease  of  liver,  733 

in  angemia,  233 

in  atrophic  cirrhosis  of  liver,  737 

in  congenital  atelectasis,  463 
heart  disease,  538 

in  difficult  digestion,  7 

in  empyema,  447 

in  gastric  catarrh,  231 ,  611 

in.  gastro-intestinal  haemorrhage,  656 

in  haemophilia,  244 

in  haemorrhagic  purpura,  250 

in  healthy  infants,  7 

in  hypertrophied  spleen,  338 

in  inherited  syphilis,  7,  210 

in  leucocythemia,  217 

in  lymphadenoma,  234 

in  pleurisy,  446 

in  rickets,  141 

in  scurvy,  256 

in  tuberculosis,  acute,  195 

pasty,  from  constipation,  619 
Conduction  of  sounds  in  chest,  404 
Congenital  cataract,  261 

rickets,  135 

syphilis  (see  Syphilis,  Inherited),  203 
Conidia  of  trichophyton  tonsurans,  800 
Constipation,  617 

after  chronic  dysentery,  650 

after  rheumatism,  618 

aperients  for,  621 

causation  of,  617 

diagnosis  of,  630 

diet  for,  623 

impaction  of  fseces  in,  630 

in  chronic  Bright's  disease,  758 

in  enteric  fever,  77 

in  haemophilia,  246 

in  intussusception,  670 

in  peritonitis,  acute,  687 
tubercular,  696 

in  peri-typhlitis.  680 

in  renal  inadequacy,  758 

in  tubercular  meningitis,  358 

in  typhlitis,  679 

in  ulceration  of  bowels,  662 

pepsin  in  treatment  of,  622 

symptoms  of,  in  infants,  619 
in  older  children,  619 

treatment  of,  621 

value  of  enemata  in  treatment  of,  623 
Consumption,    pulmonary    (see    Phthisis, 

Pulmonary^,  502 
Convalescence  from  acute  disease,  5 


Convalescence  from  chronic  disease,  5 

often  slow  in  enteric  fever,  82 
Convulsions,  277 

at  onset  of  acute  disease,  3 

bromides  in  treatment  of,  284 

causation  of,  277 

chloral  in  treatment  of,  384 

common  in  infancy,  377 

complicating  laryngismus,  368 

consequences  of,  380 

description  of,  379 

diagnosis  of.  281 

during  dentition,  278,  560 

causes  of,  560 
from  anaemia  of  brain,  251,  278 
from  arachnoid  hemorrhage,  324 
from    blood-poisoning    in    malignant 

scarlet  fever,  37 
from  cerebral  disease,  363 
from  collapse  of  lung,  378,  467 
from  earache,  378,  348 
from  lead  given  medicinally,  379 
from  peripheral  irritation,  378 
from  ureemia,  382 

treatment  of,  46 
imbecility  after,  281 
in  acute  tuberculosis,  196 
in  cerebral  haemorrhage,  324 
in  cerebro-spinal  fever,  69 
in  congenital  malformation  of  heart,. 

540 
in  encephalitis,  351 
in  enteric  fever,  79 
in  erysipelas,  111 
in  infantile  spinal  paralysis,  373 
in  intussusception,  671 
in  leucocythemia,  218 
in  lymphadenoma,  237 
in  measles,  83,  25 
in  melaena  neonatorum,  656 
in  purulent  meningitis,  349 
in  rickets,  143 
in  scarlet  fever,  34 
in  spontaneous  gangrene,  170 
in  tubercular  meningitis,  360 
in  tumour  of  brain,  332 
in  umbilical  phlebitis,  719 
in  whooping-cough,  119 
diagnosis  of,  123 
treatment  of,  127 
internal  (see  Laryngismus  Stridulus), 

267 
nitrite  of  amyl  in  treatment  of,  285 
paralysis  after,  280 
prognosis  in,  383 
rare  as  a  consequence  of  indigestion, 

601 
rare  in  wasted  mfants,  3,  277 
reflex,  frequent  in  rickets,  143 
stupor  after,  281 
treatment  of,  384 
Cornea,  ulceration  of,  in  facial  paralysis, 

369 
in  small-pox,  59 

treatment  of,  64 
Coryza,  scarlatinous,  38 


IjS^DEX. 


817 


Coryza,  scarlatinous,  treatment  of,  64 
Coryza,  syphilitic,  209 
Cough,  characters  of,  in  bronchial  asthma, 
521 

in  bronchitis,  acute,  483 
chronic,  485 

in  catarrhal  pneumonia,  437 

in  chronic  enlargement  of  tonsils,  588 

in  chronic  laryngitis,  408 

in  cirrhosis  of  lung,  476 

in  croupous  pneumonia,  424 

in  enlargement  of  bronchial  glands, 
182 

in  follicular  pharyngitis,  578 

in  foreign  body  in  air-tubes,  528 

in  gangrene  of  lung,  498 

in  measles,  24 

in  membranous  croup,  95,  413 

in  oedema  of  glottis,  408 

in  phthisis,  acute,  506 

chronic  pneumonic,  509 
tubercular,  511 

in  retro-pharyngeal  abscess,  593 

in  stridulous  laiyngitis,  412 

in  tubercular  laryngitis,  416 

in  valvular  disease  of  heart,  547 

iu  warty  growths  on  larynx,  417 
'        in  whooping-cough,  116 
Counter-irritation,  value  of,  17 
Cow-pox,  51 
Cranio-tabes  in  inherited  syphilis,  208 

in  rickets,  138 
Cretmism,  392 

absence  of  thyroid  gland  in,  393 

affinity  of,  with  congenital  rickets,  135 

causation  of,  392 

defective  sight  in,  394 

diagnosis  of,  396 

early  ossification  of  skull  in,  393 

fatty  masses  above  collar-bones  in,  393 

hearing  normally  acute  in,  394 

large  size  of  head  in,  394 

Virchow's  views  of,  393 
Crisis  in  croupous  pneumonia,  429 
Croton  chloral  in  treatment  of  whooping- 
cough,  126 
Croup,  false  (see  Stridulous  Laryngitis),  411 
Croup,  membranous,  95 

apnoea  in,  99 

death  in,  96 

diagnosis  of,  101 

diagnosis   from  foreign  body  in   air- 
tubes,  101,  533 
from  oedema  of  glottis,  490 
from    retro-pharyngeal     abscess, 

594 
from  stridulous  laryngitis,  413 

duration  of,  96 

dyspnoea  in,  96 

nature  of,  88 

prognosis  in,  102 

symptoms  of,  95 

tracheotomy  in,  105 

treatment  of,  105 
Croupous    pneumonia     (see     Pneumonia, 
Croupous),  422 
52 


Cry  in  earache,  9 

Cry  in  infancy,  absence  of,  10 

significance  of,  8 

varieties  of,  8 
Cry  in  sclerema,  807 
Cyanosis  (see  Heart  Disease,  Congenital), 

535 
Cystitis,  tubercular,  197 

Dactyi.itis,  syphilitic,  207 

diagnosis  of,  212 
Deafness  a  cause  of  late  talking,  395 

from  enlarged  tonsils,  587 

from  follicular  pharyngitis,  579 

from  quinsy,  585 

in  caries  of  petrous  bone,  369 

in  cerebro-spinal  fever,  71 

in  enteric  fever,  79 

in  inherited  syphilis,  211 

in  measles,  23 

in  mumps,  66 

in  scrofula,  177 
Death,  sudden,  in  infancy,  5,  270,  374 

in  pleurisy,  458 
Deformities  in  rickets,  137 
Deglutition  in  diphtheria,  100 
Delirium,  causes  of,  262 

early,  with  fever,  in  croupous  pneu- 
monia, 262,  425,  430 

evidence  of,  in  infants,  262 

from  debility,  262 

from  disseminated  emboli  of  brain,  158 

in  acute  infantile  spinal  paralysis,  373 
peritonitis,  687 
rheumatism,  159 

in  cerebro-spinal  fever,  70 

in  chorea,  303 

in  croupous  pneumonia,  262,  425,  430 

in  debility,  262 

in  diphtheria,  95,  97 

in  dysentery  a  fatal  sign,  651 

in  enteiic  fever,  77,  79 

in  infants,  262 

in  measles,  24 

in  mumps,  66 

in  purulent  meningitis,  350 

in  scarlet  fever,  36,  43 

in  small-pox,  60 

in  tubercular  meningitis,  359 

significance  of,  262 
Dentition  (see  Teething),  555 
Desquamation  in  erysipelas,  112 

in  erythema  papulatum,  783 

in  measles,  23 
Desquamation  in  scarlet  fever,  36 

earliest  sign  of,  42 

postponed,  36,  42 

treatment  of,  47 
Diagnosis  of  ague,  146 

of  air-passages,  foreign  body  in,  523 

of  alopecia  areata,  781 

of  anaemia,  233 

of  ascites,  702 

of  asthma,  bronchial,  523 

of  atelectasis,  congenital,  463 
post-natal,  469 


818 


INDEX. 


Diagnosis  of  atrophy,  infantile,  602 
of  bowels,  ulceration  of,  664 
of  brain,  congestion  of,  319 

hgemorrhage  into,  328 

tumour  of,  337 
of  Bright' s  disease,  chronic,  759 
of  bronchial  asthma,  523 

glands,  enlargement  of,  185,  522 
of  bronchiectasis,  514 
of  bronchitis,  485 
of  calculus  of  kidney,  767 
of  cancrum  oris,  569 
of  cardiac  dyspnoea,  98 
of  cerebellar  tumour,  337 
of  cerebral  apoplexy,  328 

congestion,  319 

embolism,  551 

paralysis,  377 

sinuses,  thrombosis  of,  353 

tumour,  337 
of  cerebro-spinal  fever,  72 
of  chicken-pox,  49 
of  chorea,  304 

of  club-foot  from  infantile  spinal  pa- 
ralysis, 377 
of  colic,  674 
of  congenital  syphilis,  211 

malformation  of  heart,  540 
of  constipation,  620 
of  contraction,  tonic,  of  extremities, 

275 
of  convulsions,  281 
of  cretinism,  396 
of  croup,  false,  413 

membranous,  101 
of  cyanosis,  540 

of  dentition,  derangements  of,  561 
of  diarrhoea,  choleraic,  644 

inflammatory,  634 
of  dilated  bronchi,  514 
of  diphtheria,  100 
of  diphtheritic  paralysis,  101 
of  dysentery,  650,  674 
of  dyspnoea,  cardiac,  98 

paroxysmal,  521 
of  eczema,  792 
of  emphysema,  494 
of  empyema,  454 
of  encephalitis,  353 
of  endocarditis,  acute,  162 

ulcerative,  162 
of  enteric  fever,  63 
of  epidemic  roseola,  31 
of  epilepsy,  290 
of  erysipelas,  112 
of  erythema  simplex,  783 

nodosum,  784 
of  facial  paralysis,  369 
of  fsecal  masses  in  bowels,  186,  664 
of  foreign  body  in  air-tubes,  531 
of  gangrene  of  lung,  499 

spontaneous,  170 
.  of  gangrenous  varicella,  49 
of  generalised  myelitis,  377,  382 
of  hfemophilia,  245 
of  haemorrhage,  gastro-intestinal,  657 


Diagnosis  of  haemorrhage  into  spinal  cord, 

377 
of  heart,  congenital  disease  of,  540 

valvular  disease  of,  550 
of  hydatid  of  liver,  740 
of  hydrocephalus,  acute,  362 

chronic,  345 
of  hydronephrosis,  703,  774 
of  hydrothorax,  455 
of  hysterical  aphonia,  409 
of  icterus  neonatorum,  719 
of  idiocy,  395 

of  infantile  spinal  paralysis,  377 
of  inherited  syphilis,  211 
of  intussusception,  673 
of  jaundice,  'il9 
of  kidney,  calculus  of,  767 

tumour  of,  773 
of  laryngismus  stridulus,  271 
of  laryngitis,  chronic,  409 

simple,  408 

stridulous,  413 

tubercular,  417 
of  larynx,  abscess  of,  420 

auEemia  of,  409 

oedema  of,  414 

scald  of,  409 

warty  growths  of,  417 
of  leucocythemia,  218 
of  liver,  amyloid,  732 

cirrhosis  of,  729 

congestion  of,  729 

fatty,  736 

hydatid  of,  740 
of  lung,  collapse  of,  469 

fibroid,  478 

gangrene  of.  499 
of  lymph  adenoma,  227 
of  measles,  26 
of  megrim,  296 
of  meningitis,  purulent,  353 

tubercular,  362 
of  molluscum  contagiosum,  797 
of  mumps,  67 
of  myelitis,    acute   generalised,    377, 

382 
of  nettlerash,  786 
of  oedema  of  larynx,  414.  594 
of  oedema  of  new-born  infants,  808 
of  otitis,  352 
of  paralysis,  cerebral,  377 

diphtheritic,  101 

facial,  369 

infantile  spinal,  377 

pseudo-hypertrophic,  387 

spasmodic  spinal,  382 
of  pemphigus,  780 
of  pericarditis,  161 

suppurative,  163 
of  peritonitis,  acute,  674,  689 

tubercular,  697 
of  perityphlitis,  683 
of  i^haryngitis.  follicular,  579 

herpetic,  580 

tubercular,  582 
of  phthisis,  fibroid,  478 


INDEX. 


819 


Diagnosis  of    phthisis,  pulmonary,   acute, 
507 
pulmonary,  chronic,  513 
of  pleurisy,  453 
of  pneumonia,  catarrhal,  439 
cerebral,  430 
croupous,  430 
of  portio  dura,  paralysis  of,  869 
of  purpura  hemorrhagica,  351 

simplex,  251 
of  quinsy,  588 

of  retro-pharyngeal  abscess,  594 
of  rheumatism,  acute,  161 

of  abdominal  muscles,  161 
of  rickets,  143 
of  ringworm,  801 
of  roseola,  787 
of  scabies,  799 
of  scarlet  fever,  41 
of  sclerema,  808 
of  scrofula,  185 
of  scurvy,  257 
of  small-pox,  61 

of  spasmodic  spinal  paralysis,  382 
of  spinal  caries,  185 
of  spleuic  tumour,  240 
of  spontaneous  gangrene,  170 
of  stomatitis,  aphthous,  564 
gangrenous,  569 
ulcerative,  566 
of  syphilis,  inherited,  211,  602 
of  teething,  derangements  of,  561 
of  tetanus,  312 
of  tetany,  275 
of  thrash,  574 
of  tinea  circinata,  801 
favosa,  805 
tonsurans,  801 
of  tuberculosis,  198 
in  infants,  199 

in  infants  from  infantile  atrophv. 
601  •^' 

of  tumour  of  brain,  337 

of  kidney,  773 
of  typhlitis,  682 
of  ulceration  of  bowels,  664 
of  urticaria,  786 
of  varicella,  49 
of  variola,  61 
of  varioloid,  49 
of  variolous  roseola,  61 
of  vulvitis,  aphthous,  776 
of  whooping-cough,  122 
of  worms,  intestinal,  711 
Diaphragm,  paralysis  of,  100 

diagnosis  of,  102 
Diaphragm,  spasm  of,  270 
Diarrhoea,  choleraic,  642 
causation  of,  642 
collapse  in,  643 
diagnosis  of,  644 
duration  of,  644 
hypodermic  injection  of  morphia  in, 

646 
koumiss  in  treatment  of,  644 
morbid  anatomy  of,  642 


Diarrhoea,  choleraic,  prognosis  in,  644 
rapid  wasting  in,  643 
saUcylate  of  lime  m  treatment  of,  645 
stools  in,  643 
symptoms  of,  642 
temperature  in,  643 
treatment  of,  644 
vomiting  in,  643 
Diarrhoea,  chronic,  633 
diagnosis  of,  634 
diet  in,  640 

nitrate  of  silver  in  treatment  of,  641 
prognosis  in,  635 
raw  meat  in  treatment  of,  640 
symptoms  of,  633 
treatment  of,  640 
Diarrhoea  from  fsecal  accumulation  in  rec- 
tum, 619 

diagnosis  of,  621 
in  cases  of  ulceration  of  bowels,  662 
Diarrhoea,  inflammatory,  629 

astringents  in  treatment  of,  638 
causation  of,  629 
character  of  stools  in,  630 
cold  bathing  in  treatment  of,  637 
diagnosis  of,  634 
diet  in,  686 

ipecacuanha  in  treatment  of,  638 
morbid  anatomy  of,  630 
parenchymatous  nephritis  in,  632 
prognosis  in,  635 
rapid  wasting  in,  631 
spurious  hydrocephalus  in,  632 
symptoms  of,  630 
temperature  in,  631 
treatment  of,  636 
Diarrhoea,  lienteric,  626 

treatment  of,  628 
nocturnal,  from  lumbricus,  710 
Diarrhoea,  simple,  624 
causation  of,  624 
morbid  anatomy  of,  626 
relation  of,  to  teething,  556 
symptoms  of,  625 
treatment  of,  626 
Diathesis,  the  scrofulous,  175 

two  types  of,  176 
Diathetic  diseases,  the,  173 
Diet  in  anaemia,  234 
in  ascites,  704 
in  atelectasis,  congenital,  464 

post-natal.  472 
in  atrophy,  infantile,  603 
in  Bright's  disease,  acute,  46 

chronic,  761 
in  bronchitis,  487 
in  calculus  of  kidney,  768 
in  cancrum  oris,  569 
in  cerebral  haemorrhage,  329 
in  chorea,  305 
in  congenital  syphilis,  214 
in  constipation,  623 
in  dentition,  562 
in  diarrhoea,  choleraic,  644 
inflammatory,  acute,  536 
inflammatory,  chronic,  640 


820 


INDEX. 


Diet  in  diphtheria,  103 

in  dysentery,  acute,  651 

chronic,  653 
in  eczema,  793 
in  emphysema,  495 
in  empyema,  460 
in  enteric  fever,  85 
in  epilepsy,  292 
in  erysipelas,  113 
in  erythema  nodosum,  785 
in  extremities,    tonic  contraction  of, 

276 
in  gangrene  of  lung,  501 

spontaneous,  171 
in  gastric  catarrh,  607,  615 
in  hgemophilia,  246 
in  heart,  valvular  disease  of,  553 
in  icterus  neonatorum,  721 
in  idiocy,  397 
in  intussusception,  677 
in  kidney,  calculus  of,  768 
in  laryngismus  stridulus,  273 
in  laryngitis,  411 
in  larynx,  suppuration  about,  421 
in  liver,  congestion  of,  724 

cirrhosis  of,  730 
in  lung,  collapse  of,  464,  472 

fibroid,  480 

gangrene  of,  501 
in  measles,  29 
in  megrim,  298 
in  melaena  neonatorum,  659 
in  mumps,  67 
in  night  terrors,  562 
in  peritonitis,  acute,  691 

tubercular,  699 
in  perityphlitis,  684 
in  pharyngitis,  herpetic,  581 

tubercular,  o83 
in  phthisis,  fibroid,  480 

pulmonary,  acute,  517 

pulmonary,  chronic,  517 
in  pleurisy,  457 
in  pneumonia,  catarrhal,  442 

croupous,  432 
in  purpura,  252 
in  quinsy,  589 
in  rheumatism,  acute,  164 
in  rickets,  144 
in  scarlet  fever,  44 
in  sclerema,  809 
in  scrofula.  187 
in  scurvy,  258 
in  small-pox,  62 
in  splenic  tumour,  240 
in  spontaneous  gangrene,  171 
in  stomatitis,  gangrenous,  569 

ulcerative,  566 
in  syphilis,  infantile,  214 
in  teething,  562 
in  tetanus,  313 
in  tetany,  276 
in  thrush,  575 
in  tuberculosis,  201 
in  typhlitis,  684 
in  ulceration  of  bowels,  666 


Diet  in  urticaria,  786 

in  whooping-cough,  124 
Digitalis  as  a  diuretic  for  children,  47 

value  of.  in  heart  disease,  553 
Diphtheria,  89 

albuminuria  in,  95 

and  croup,  identity  of,  88 

antiseptic  sprays  in,  104 

cardiac  thrombosis  in,  98 

causation  of,  90 

complicating  scarlatina,  38 

complications  of.  97 

diagnosis  of,  100 

diet  in,  103 

failure  of  heart  in,  99 

false  membrane  of,  92 

forced  feeding  in,  107 

infection,  duration  of,  in.  90 

laryngeal  (see  Membranous  Croup),  95 

local  remedies  in,  104 

malignant,  97 

mild  form  of,  93 

morbid  anatomy  of,  91 

nasal,  98  i 

paralytic  lesions  in,  99 

prognosis  in,  102 

secondary,  97 

severe  form  of,  94 

sudden  death  in,  99 

symptoms  of,  93 

temperature  in,  95 

treatment  of,  103 

urine  in,  95 

varieties  of,  93 
Douche,  cold,  in  treatment  of  chorea,  305 

of  laryngismus  stridulus,  272 

of  rickets,  146 

of  scrofula,  188 
Douche,  cold,  precautions  in  giving,  17 

therapeutic  value  of,  16 
Dover's  powder  in  treatment  of  dysentery, 
652 

of  inflammatory  diarrhoea,  638 
Drinking,  mode  of,  significance  of,  13 
Dropsy  after  scarlet  fever,  39 

in  acute  Bright's  disease,  39 

in  chronic  Bright's  disease,  754 

in  heart  disease,  547 
Drowsiness  after  cinvulsions,  262,  280 

as  a  sign  of  cerebral  disease,  262 

from  disturbed  sleep,  320 

in  acquired  hydrocephalus,  344 

in  ague,  149 

in  cerebral  congestion,  318 

in  congenital  atelectasis,  462 
malformation  of  heart.  540 

in  croupous  pneumonia,  425 

in  enceiDhalitis,  351 

in  hypertrophic  cirrhosis  of  liver,  729 

in  lymphadenoma,  224 

in  malignant  scarlet  fever.  37 

in  purulent  meningitis.  349 

in  spasmodic  stage  of  whooping-cough, 
116 

in  spontaneous  gangrene,  168 

in  tubercular  meningitis,  359 


INDEX. 


821 


Drowsiness  in  uraemia,  755 
significance  of,  362 

Ductus  arteriosus,  time  of  closure  of,  536 

Dyspnoea,  cardiac,  98 
causes  of,  519 
definition  of,  519 
expiratory,  523 
from  ascites,  701 

from  clotting  of  blood  in  heart,  98 
from  congenital  malformation  of  heart, 

538,  541 
from  embarrassed  pulmonary  circula- 
tion, 427 
from  enlarged  bronchial  glands,  182, 

523 
from  foreign  body  in  air- tubes,  527 
from  interstitial  oedema  of  lung,  39 
from  membranous  laryngitis,  96 
from  oedema  of  glottis,  407 
from  p  iralysis  of  diaphragm,  100 
from  pressure  on  larynx,  420 

on  lung,  449,  519 
from  retro-pharyngeal  abscess,  592 
from  sarcoma  of  kidney,  771 
from  scald  of  glottis,  407 
from  softened  ribs  in  rickets,  519 
from  stridulous  laryngitis,  4l3 
from  suppuration  about  larynx,  419 
in  acute  pulmonary  phthisis,  506 
in  bronchial  asthma,  521 
in  capillary  bronchitis,  484 
in  catarrhal  pneumonia,  437 
in  croupous  pneumonia,  427 
in  diphtheria,  96 
in  peritonitis,  687 
in  pleurisy,  449 
in  pulmonary  gangrene,  498 
in  valvular  disease  of  heart,  547 
inspiratory,  522 

Dyspnoea,  paroxysmal,  causes  of,  519 
definition  of,  520 
diagnosis  of,  531 

Ear,  haemorrhage  from,  in  hsemorrhagic 
purpura,  349 

in  melsena  neonatorum,  656 

in  pertussis,  118 
Ear,  intlammation  of  middle  (see  Otitis), 
345 

malformation  of,  in  the  idiot,  396 

position  of,  in  the  idiot,  396 
Earache,  convulsions  from,  348 

peculiar  cry  of,  9 

signs  of,  in  the  infant,  348 
Eclampsia  (see  Convulsions),  277 
Ecthyma,  780 
Eczema,  789 

capitis,  790 

causation  of,  789 

diagnosis  of,  792 

diet  in,  793 

infantile,  791 

rubrum,  790 

simplex,  790 

symptoms  of,  790 

tarsi,  791 


Eczema,  treatment  of,  792 

varieties  of,  790 
Emboli  oE  minute  arteries  as  a  cause  of 

chorea,  300 
Embolism,  cerebral,  case  of,  548 

of  umbilical  veins  a  cause  of  haemor- 
rhage from  navel,  654 
Embolisms,  various,  in  cases  of  ulcerative 

endocarditis,  158,  547 
Emetics  in  treatment  of  bronchitis,  487 
of  collapse  of  lung,  4(54,  471 
of  fibroid  induration  of  lung,  480 
of  stridulous  laryngitis,  414 
Emphysema,  pulmonary,  491 
causation  of,  491 
diagnosis  of,  494 
diet  in,  495 

morbid  anatomy  of,  493 
prognosis  in,  495 
symptoms  of,  493 
treatment  of,  495 
Empyema,  477 

(ilubbing  of  fingers  in,  455 
diagDosis  of,  454 
diet  in,  460 
symptoms  of,  447 
temperature  in,  447 
treatment  of,  458 
Encephalitis,  347 

convulsions  in,  351 
diagnosis  of,  162 
duration  of,  351 
morbid  anatomy  of,  347 
paralysis  in,  351 
pulse  in,  351 
stupor  in,  351 
symptoms  of,  351 
temperature  in,  351 
treatment  of,  354 
Endocarditis,  rheumatic,  155 
diagnosis  of,  162 
morbid  anatomy  of,  154 
prognosis  in,  163 
rest,  importance  of,  in,  165 
treatment  of,  165 
Endocarditis,  ulcerative,  154 
diagnosis  of,  162,  552 
morbid  anatomy  of,  154 
symptoms  of,  154,  547 
Enemata,  astringent,  in  diarrhoea,  639 
in  dysentery,  653 
in  ulceration  of  bowels,  667 
Enemata,  sedative,  in  prolapsus  ani,  639 
value  of,  in  treatment  of  constipation, 
633 
Enteric  fever,  74 
causation  of,  74 
cervical  neuralgia  in,  79 
character  of  stools  in,  77 
complications  of,  81 
constipation  in,  77 
deafness  in,  72 

defective  action  of  kidneys  in,  82 
diagnosis  of,  83 
from  acute  gastric  catarrh,  83 
from  acute  tubercular  peritonitis,  698 


822 


INDEX. 


Enteric   fever,   diagnosis  of,    from   acute 

tuberculosis,  83 

from  inflammatory  diarrhoea,  83 

from  leucocythemia,  218  *. 

from  tubercular  meningitis,  83 

from  typhus  fever,  84 

from  ulceration  of  the  bowels,  84 

digestive  organs  in,  76 

duration  of,  80 

eruption  in,  77 

headache  in,  76 

incubation  period  of,  76 

melsena  in,  78 

mode  of  death  in,  81 

morbid  anatomy  of,  75 

perforation  of  bowel  in,  81; 

prognosis  in,  84 

pulse  in,  79 

retention  of  urine  in,  78 

secondary  pyrexia  in,  83 

sequelae  of,  82 

swelling  of  abdomen  in,  78 

symptoms  of,  76 

temperature  in,  79 

treatment  of,  85 

urine  in,  78 
Entero-colitis    (see    Diarrhoea,  Inflamma- 
tory), 629 
Enuresis   (see    Urine,  Nocturnal    Inconti- 
nence of),  748 
Epidemic  roseola,  30 

diagnosis  of,  31 

symptoms  of,  30 

treatment  of,  30 
Epigastrium,  pain  in,  as  a  sign  of  spinal 

caries,  178 
EpUepsy,  286 

association  of,  with  chorea,  290 

bromides  for,  292 

causation  of,  286 

diagnosis  of,  290 

diet  in,  292 

influence  of,  on  mental  development, 
289 

pathology  of,  287 

prognosis  in,  291 

symptoms  of,  287 

treatment  of,  291 
Epileptic  vertigo,  288 
Epiphyses,  ossification  of,  in  rickets,  182 

separation  of,  in  infantile  syphilis,  210 
in  scurvy,  256 
Enistaxis  from  enlarged  bronchial  glands, 
181 

in  acute  tuberculosis,  194 

in  anaemia,  233 

in  atrophic  cirrhosis  of  liver,  728 

in  enteric  fever,  79 

in  fibroid  induration  of  lung,  477 

in  haemophilia,  243 

in  haemorrhagic  purpura,  249 

in  heart  disease,  547 

in  idiopathic  anaemia,  233 

in  leucocythemia,  218 

in  lymphadenoma,  226 

in  measles,  25 


Epistaxis  in  splenic  enlargement,  238 

in  whooping-cough,  116 

simulating  haemoptysis,  117,  477 
haematemesis,  117,  654 
melaena,  117 

treatment  of,  252 

in  haemophilia,  246 
Ergot  in  treatment  of  epilepsy,  293 

of  incontinence  of  urine,  750 

of  haemoptysis,  518 

of  megrim.  297 
Eruption  (see  Rash) 
Erysipelas,  109 

abscesses  in,  110 

causation  of,  109 

complications  of,  110 

desquamation  of  skin  in,  112 

diagnosis  of,  112 

diet  in,  113 

duration  of,  112 

gangrenous  sloughs  in,  110 

idiopathic,  112 

laryngitis  in,  110 

local  applications  in,  113 

morbid  anatomy  of,  110 

prognosis  in,  112 

puerperal,  110 

symptoms  of,  1 11 

temperature  in,  110 

treatment  of,  113 

white  lead  paint  as  an  application  for, 
113 
Erythema  fugax,  782 
Erythema  intertrigo.  782 

symptoms  of.  782 

treatment  of,  783 
Erythema  nodosum,  783 

diagnosis  of.  784 

symptoms  of,  783 

temperature  in,  784 

treatment  of.  784 
Erythema  papulatum,  782 
Erythema  simplex,  782 

diagnosis  of.  783 

treatment  of,  783 

varieties  of,  782 
Examination,  clinical,  of  infants,  6 

of  abdomen,  12 

of  chest,  399, 

of  fontanelle,  9 

of  liver,  723 

of  mouth,  13 

of  spleen,  237 

of  stools  in  diarrhoea,  14 

of  throat,  13 

of  tongue,  13 
Exanthemata   in   the   subjects   of  hemo- 
philia, 245 

of  scrofula,  24,  42,  174 
Exercise,  want  of,  a  cause  of  constipation, 

619 
Expectorants  in  bronchitis,  487 
,  Expression,  distressed,  a  sign  of  disease, 
i      7,  265,  663 
I  External  applications,  16 
1  Extremities,  tonic  contraction  of,  274 


INDEX. 


823 


Extremities,  tonic  contraction  of,  calabar 
bean  in  treatment  of,  376 
causation  of,  274 
diagnosis  of,  275 
prognosis  in,  276 
symptoms  of,  274 
treatment  of,  276 
Eye,  position  of,  in  the  idiot,  396 
Eyeball,  destruction  of,  in  facial  paralysis, 
369 
in  small-pox,  59 
Eyelids,   bleeding   from,    in  hasmorrbagic 
purpura,  249 
half  closed    during    sleep    a    sign   of 
prostration,  8 
Eyes,  bloodshot,  in  whooping-cough,  118 
prominent  in  chronic  hydrocephalus, 
342 

Face,  expression  of,  in  infants,  6 
Facial  nerve  in  the  Fallopian  canal,  367 

paralysis  (see  Portio  Dura,  Paralysis 
of),  367 
Facies,  distressed,  a  sign  of  disease,  7,  663 
F«cal  concretions,  678 

masses  in  bowel,  diagnosis  of,  186,  664 
Faeces,  accumulation  of,  in  bowels,  620 
Faeces,  impaction  of,  619 

diagnosis  of,  674 

seat  of,  619 

symptoms  of,  619 

treatment  of,  623 
Faradisation  of  muscle  in  infantile  spinal 
paralysis,  378 

of  spleen  in  leucocythemia,  219 
Fatty  degeneration  of  liver  in  entero-co- 
litis,  735 

of  organs  in  anaemia,  232 

of  organs  in  purpura,  248 
Fauces  (see  Throat) 

Features,  alteration  of,  in  follicular  pha- 
ryngitis, 579 

in  hypprtrophy  of  tonsils,  587 
Feeding,  forced,  of  children,  15 
Feet,  coldness  of,  in  anajmia,  232 

in  congenital  malformation  of  heart, 
538 
Fever,  general  considerations  on,  10 

irritative,  10 
Fibroid  induration  of  lung,  473 

amyloid  degeneration  of  organs  in,  477 

contraction  of  side  in,  477 

diagnosis  of,  478 

diagnosis  from   pleurisy  with  retrac- 
tion, 478 
from  pulmonary  phthisis,  478 

dilatation  of  bronchi  in,  474 

morbid  anatomy  of.  474 

offensive  sputum  in,  477 

paroxysmal  cough  in,  476 

pathology  of,  473 

physical  signs  of,  476 

prognosis  in,  479 

symptoms  of.  475 

temperature  in,  477 

treatment  of,  478 


Fibroid  nodules  in  acute  rheumatism,  160 

Fibroid  phthisis,  475,  477 

Fingers,  clubbing  of,  in  amyloid  liver,  732 

in  chronic  bronchitis,  485 

in  cirrhosis  of  lung,  477 

in  congenital  heart  disease,  526 

in  empyema,  455 
I  Flatulence,  619 

treatment  of,  622 
Flea-bites,     petechias    from,    in    anemic 

children,  233 
Fluid  in  chronic  hydrocephalus,  341 

in  hydatid  cysts,  737 

in  hydronephrosis,  772 

in  pleurisy,  444 
Flush,  cerebral,  265,  3o9 
Flushing  of  face  in  acute  tuberculosis,  195 

in  croupous  pneumonia,  425 

in  enteric  fever,  77 

in  leucocythemia,  217 

in  lymphadenoma,  224 

in  tubercular  meningitis,  359 
Foetus,  circulation  in  the,  at  term,  535 
Fontanelle  in  chronic  hydrocephalus,  341 

in  idiocy,  396 

in  rickets,  137 

in  syphilis,  inherited.  210 

in  tubercular  meningitis,  360 

in  wasted  infants,  9 
Food  (see  Diet) 

farinaceous,  as  a  diet  for  infants,  604 
Foramen  ovale,  closure  of  the,  536 

patency  of  the,  539 
Foreign  body  in  air-tubes,  526 

diagnosis  of,  523,  531 

dyspnoea  from,  522,  523,  527 

morbid  anatomy  of,  526 

pain  in  chest  in,  527 

physical  signs  of,  528 

prognosis  in,  533 

seat  of,  530 

spasmodic  cough  from,  527 

spontaneous  expulsion  of,  529 

symptoms  of,  527 

treatment  of,  533 
Fremitus,  vocal,  often  absent  in  early  life, 

401 
Friction,  pericardial,  156 

pleural,  449 
Fright  as  a  cause  of  chorea,  299 

of  epilepsy,  286 

of  incontinence  of  urine,  748 
Function,  disorder  of,  in  childhood,  3 

G-AIT,  peculiarities    of,  in    cerebellar  tu- 
mour, 337 

in  pseudo-hypertrophic  paralysis,  385 

in  spasmodic  spinal  paralysis,  382 
Galvanism  in  facial  paralysis,  370 

in  hysterical  affections,  266 

in  infantile  spinal  paralysis,  378 

in  leucocythemia,  219 

in  pseudo-hypertrophic  paralysis,  385 
Gangrene  following  scarlet  fever,  40 

of  cheek  (see  Stomatitis,  Gangrenous), 
567 


824 


INDEX. 


Gangrene,  pulmonary,  496 

causation  of,  496 

diagnosis  of,  499 

diet  in,  501 

duration  of,  499 

dyspnoea  in,  498 

hgemoptysis  in,  498 

morbid  anatomy  of,  497 

physical  signs  of,  499 

prognosis  in,  500 

pulse  in,  498 

respirations  in,  498 

symptoms  of,  497 

temperature  in,  498 

treatment  of,  500 
Gangrene,  spontaneous,  166 

causation  of,  166 

cause  of  death  in,  170 

diagnosis  of,  170 

diet  in,  171 

hsematuria  in,  168 

iodoform  in  treatment  of,  171 

local  applications  for,  171 

morbid  anatomy  of,  167 

of  extremities,  169 

of  vulva,  170 

pathology  of,  166 

prognosis  in,  171 

symmetrical,  167 

symptoms  of,  167 

temperature  in,  170 

treatment  of,  171 

varieties  of,  167 
Gangrenous  sloughs  in  erysipelas,  110 

in  varicella,  49 
Gastric  catarrh  in  infants,  601 

diet  in,  607 

incapacity  for  digesting  milk  in,  606 

often  a  cause  of  death,  598 

synaptoms  of,  601 

treatment  of,  606 

vomiting  from,  601 
Gastric  catarrh  in  older  children,  609 

causation  of,  609 

diagnosis  of,  612 

diet  in,  615 

febrile  form  of,  610 

jaundice  in,  610,  614 

morbid  anatomy  of,  610 

nervous  symptoms  in,  611 

non-febrile  form  of,  611 

symptoms  of,  610 

tongue  in,  611 

treatment  of,  615 
Gelatine  in  the  hand-feeding  of  infants,  604 
Gelatiniform  softening  of  bone  in  inherit- 
ed syphilis,  207 
Giant  cells  in  tubercle,  192 
Glandular  enlargement  in  lymphadenoma, 

220 
Glands,  bronchial  (see  Bronchial  Glands), 
178 

mesenteric   (see  Mesenteric    Glands), 
183 

post -cervical,    enlarged    in    epidemic 
roseola,  31 


Glands,  post-cervical,  enlarged  in  inherit- 
ed syphilis.  210 
Gliomatous  tumour  of  brain,  case  of,  333 
Glottis,  catarrh  of  (see  Laryngitis),  406 
impaction  of  foreign  body  in,  529 
oedema  of,  409 

diagnosis  of,  413 
treatment  of,  410 
scald  of,  407 

spasm  of  (see  Laryngismus  Stridulus), 
267 
Goitre  in  endemic  cretinism,  396 
Granulation,  the  gray,  190,  192 
Growth,  rapid,  pyrexia  from,  11 
retarded  in  cretinism,  393 
in  idiocy,  392 

in  infantile  spinal  paralysis,  373 
in  inherited  syphilis,  211 
in  rickets,  140 
Guiaiacum  as  a  remedy  for  acute  eczema, 

793 
Gums,  bleeding  from,  in  ansemia,  233 
in  cirrhosis  of  liver,  728 
in  hfemophilia,  243 
in  melsena  neonatorum,  656 
in  purpura  hgemorrhagica,  249 
in  scurvy,  256 
in  ulcerative  stomatitis,  565 
Gums  in  cyanosis,  539 

in  gangrenous  stomatitis,  567 
in  purpura,  250 
in  scurvy,  256 

in  ulcerative  stomatitis,  565 
lancing  of,  in  convulsions  of  teething, 
562 

H.EMATEMESis,  spurious,  654 

causes  of,  654 

diagnosis  of,  657 
Hsematemesis,  true,  causes  of,  654 

diagnosis  of,  657 

in  hsemophilia,  243 

in  hsemorrhagic  purpura,  ^49 

in  infants,  654 

in  intussusception,  672 

prognosis  in,  658 

treatment  of,  659 
Hsematomata       on      auriculo -ventricular 

valves,  546 
Hsematuria,  causes  of,  746 

from  calculus  of  kidney,  765 

from  embolism  of  kidney,  158    • 

from  irritation  of  passages  by  the.bil- 
harzia  hjematobia,  747 

from  sarcoma  of  kidney,  765 

in  ague,  149 

in  asthenic  measles,  24 

in  Bright' s  disease,  acute,  39 
chronic,  765 

in  cerebro-spinal  fever,  71 

in  diphtheria,  95 

in  hfemorrhagic  purpura,  249 

in  lymphadenoma.  224 

in  malignant  small-pox,  60 

in  scarlet  fever,  39 

in  scurvy,  257 


INDEX. 


825 


Haematuria  in  spontaneous  gangrene,  168 

in  ulcerative  endocarditis,  158 

rare  in  hsemophilia,  243 
Haemoglobin  reduced  in  anaemia,  239 
Hsemophilia,  242 

aperients  in,  246 

causation  of,  242 

diagnosis  of,  245 

diet  in,  246 

haemorrhages  in,  243 

joint  affection  in,  244 

morbid  anatomy  of,  243 

pains  in  limbs  in,  344 

prognosis  in,  345 

symptoms  of,  343 

three  grades  of,  343 

treatment  of,  246 
Haemoptysis   in  congenital  heart   disease, 
538 

in  disease  of  mitral  valve,  547 

in  pulmonary  gangrene,  498 
phthisis,  510 

in  whooping-cough,  116 
Haemorrhage,  cerebral  (see  Cerebral  Haem- 
orrhage), 323 

conjunctival,  in  whooping-cough,  118 

from  bowels  (see  Melsena) 

from  gums  in  anaemia,  333 
in  cirrhosis  of  liver,  738 
in  haemophilia,  243 
in  purpura  haemorrhagica,  349 
in  scurvy,  356 
in  ulcerative  stomatitis,  585 

from  tonsil  in  quinsy.  586 
Hsemorrhage,  gastro-intestinal,  654 

causation  of,  654 

diagnosis  of,  657 

prognosis  in,  658 

symptoms  of,  656 

treatment  of,  659 
Hemorrhage  into   spinal  cord,   diagnosis 
of,  377 

intra-cranial,  in  purpura,  351 
in  whooping-cough,  115 
Haemorrhage,  meningeal,  causation  of,  322 

convulsions  in,  324 

diagnosis  of,  328 

morbid  anatomy  of,  338 

prognosis  in,  339 

symptoms  of,  324 

treatment  of,  339 
Hemorrhage,    sub-periosteal,    in   scurvy, 

254 
Haemorrhages,  various,  in  asthenic   mea- 
sles, 24 

in  haemophilia,  243 

in  leucocythemia,  218 

in  purpura,  249 
Haemorrhoids  in  atrophic  cirrhosis  of  liver, 

717 
Hair  in  chronic  hydrocephalus,  343 

in  cretinism,  393 

in  rickets,  138 
Hairs  in  tinea  favosa,  804 

in  tinea  tonsurans,  800 
Hallucinations  in  cerebro-spinal  fever,  70 


Hand-feeding    of    infants    (see    Artificial 

Feeding),  603 
Head,  retraction  of,  causes  of,  264 

in  abscess  of  larynx,  419 

in  cerebro-spinal  fever,  69 

in  chronic  hydrocephalus,  343 

in  purulent  meningitis,  349 

in  retro-pharyngeal  abscess,  593 

in  tubercular  meningitis,  360 
Headache  after  fit  of  whooping-cough,  116 

hypertrophic,  297 

in  antemia,  233 

in  cerebral  tumour,  333 

in  chronic  Bright's  disease,  755 
hydrocephalus,  843 

in  croupous  pneumonia,  425 

in  diphtheria,  severe,  94 

in  enteric  fever,  79,  83 

in  gastric  catarrh,  611 

in  megrim,  295 

in  purulent  meningitis,  349 

in  rickets,  137 

in  tubercular  meningitis,  358 

in  urtemia,  39 

occipital,  in  spinal  caries,  178 
in  cerebellar  tumour,  337 

sign  of,  in  the  infant,  8 
Heart,  arrest  of  development  of.  536 

degeneration  of,  death  from,  99 
in  diphtheria,  92 

disease,  causes  of,  544 
Heart  disease,  congenital,  535 

cerebral  symptoms  in,  540 

clubbing  of  fingers  in,  538 

commonest  form  of,  536 

common  in  idiots,  396 

convulsions  in,  538 

cyanosis  in,  538 

diagnosis  of,  540 

disease  of  petrous  bone  in,  540 

dropsy  in,  538 

drowsiness  in,  540 

duration  of  life  in,  540 

dyspnoea  in,  538 

modes  of  death  in,  540 

morbid  anatomy  of,  537 

physical  signs  in,  539 

prognosis  in,  542 

resulting  from  atelectasis,  463 

symptoms  of,  538 

syncope  in,  539 

treatment  of,  542 

valvular  defects  in,  537 

varieties  of,  536 
Heart  disease  in  acute  rheumatism,  155 

in  chorea,  303 

normal  development  of,  535 
Heart,  chronic  valvular  disease  of,  544 

ante-mortem  clots  in,  550 

causation  of,  544 

diagnosis  of,  550 

diet  in,  553 

dyspnoea  in,  547 

embolism  in,  547 

haemorrhages  in,  547 

morbid  anatomy  of,  545 


826 


INDEX. 


Heart,  chronic  valvular  disease  of,  palpita- 
tion in,  547 

prognosis  in,  552 

symptoms  of,  547 

terminations  of,  550 

treatment  of,  552 

varieties  of,  549 
Heart's  apex,  displacement  of,  402 

normal  site  of,  401 
Hemi-chorea,  302 

Hemiplegia  from  embolism  of  brain,  548 
Hernia  during  spasm  of  whooping-cough, 
116 

umbUical,  from  straining  at  stool,  619 
Herpes,  779 

of    pharynx     (see    Pharyngitis,   Her- 
petic), 580 
Hip-joint  disease  simulated  by  peri-typhli- 
tis, 680 

diagnosis  of,  683 
Hoarseness  from  anaemia  of  larynx,  409 

from  chronic  laryngitis,  408 

from  enlarged  bronchial  glands,  182 

from  foreign  body  in  air-tubes,  528, 
530 

from  inherited  syphilis,  210 

from  membranous  croup,  95 

from  oedema  of  glottis,  408 

from  scald  of  glottis,  407 

from  stridulous  laryngitis,  412 

from  suppuration  about  larynx,  420 

from  tubercular  laryngitis,  416 

from  warty  growths  on  larynx,  417 
Hodgkin's  disease  (see  Lymphadenoma) 
Hum,  venous,  behind  sternum,  183 
Hunger,  sign  of,  in  the  infant,  8 
Hydatid  cyst,  suppuration  of,  739 

treatment  of,  743 
Hydatid  of  liver  (see  Liver,  Hydatid  of), 

737 
Hydrocephalus,     acute     (see     Tubercular 

Meningitis),  355 
Hydrocephalus,  chronic,  340 

acquired,  340,  344 

arrest  of  disease  in,  344 

causation  of,  340 

complicating  rickets,  142 

congenital.  340,  342 

diagnosis  of,  345 

duration  of  life  in,  344 

fluid  in.  342 

fontanelle  in,  341 

headache  in,  343 

intelligence  in,  343 

late  walking  in.  343 

mode  of  death  in,  344 

morbid  anatomy  of,  341 

nervous  symptoms  in,  343 

nystagmus  in,  343 

oedema  of  brain  in,  342 

ophthalmoscopic  examination  in,  343 

prognosis  in.  345 

retraction  of  head  in,  343 

shape  of  head  in,  341 

spontaneous  evacuation  of  fluid  in,  344 

sutures  in,  341 


Hydrocephalus,  chronic,  symptoms  of,  342 
the  senses  in,  343 
treatment  of,  345 
Hydrocephalus,  spurious,  632 
diagnosis  of,  635 
treatment  of.  639 
Hydronephrosis,  772 
acquired,  766.  772 
causation  of,  772 
diagnosis  of,  774 

from  ascites,  703 
symptoms  of,  772 
treatment  of,  774 
usually  congenital,  772 
Hyperinosis  in  acute  rheumatism,  162 
Hyper-pyrexia,   cerebral  symptoms  from, 
159 
in  rheumatism,  159 

treatment  of,  163 
in  scarlet  lever,  45 
reduction  of  temperature  In,  15 
Hypertrophy  of  muscle  in  pseudo-hyper- 
trophic  paralysis,  384 
of  right  ventricle  in  congenital  heart 

disease,  537 
of  spleen  (see  Spleen,  Simple  Hyper- 
trophy of),  238 

Ice-bag  to  head   and   spine   in  cerebro- 
spinal fever,  73 

to  head  in  tubercular  meningitis,  366 
Icterus  (see  Jaundice),  714 

malignus,  718 
Icterus  neonatorum,  714 

causation  of,  715 

dicXgnosis  of,  719 

prognosis  in,  720 

treatment  of,  720 
Idiocy,  389 

acquired,  390 

association  of,  with  malformations,  392 

Aztec  type  of,  390 

causes  of,  389 

classification  of,  391 

common  in  first-born  children,  889    - 

congenital,  392 

defective  speech  in,  394 

diagnosis  of,  395 

earliest  signs  of.  396 

insensibility  to  pain  in,  394 

mental  condition  in,  394 

morbid  anatomy  of,  390 

obtuseness  of  senses  in,  394 

prognosis  in,  396 

symptoms  of,  391 

treatment  of,  397 

varieties  of,  391 
Idiopathic  anaemia,  231 

symptoms  of,  233 
Idiopathic  contractures  (see  Extremities, 

Tonic  Contraction  of),  274 
Ilium,  catarrh  of,  stools  in,  630 
Impetigo  contagiosa,  791 
Incubation  period  in  chicken-pox,  48 

in  diphtheria,  93 

in  epidemic  roseola,  30 


INDEX. 


827 


Incubation  period  in  measles,  31 

in  mumps,  65 

in  scarlet  fever,  33 

in  small-pox,  5(3 

in  whooping-cough,  115 
Indican  in  urine,  test  for,  635 
Indigestion  a  cause  of   infantile  atrophy, 
598 

from  constipated  bowels,  620 

in  infants,  600 

treatment  of,  603 

in  older  children,  611,  613 

of  breast-milk,  599 

of  cow's  milk,  597 

treatment  of,  606,  607 

of  starch  in  infancy,  598 
Infancy,   convulsions   in,  clinical   import- 
ance of,  3 

definition  of,  5 

modes  of  death  in,  4 

nervous  excitability  in,  2 

physiological  peculiarities  of,  3 

pulse  in,  9 

respiration  in,  10,  13 

sudden  death  in,  5 

temperature  in,  10 
Infantile  atrophy,  596 

causation  of,  596 

constipation  in,  601 

diagnosis  of,  603 

diarrhoea  in,  603 

diet  in,  605 

eruptions  in,  601 

inability  to  digest  cow's  milk  in,  605 

indigestion  in,  600 

prognosis  in,  603 

state  of  bowels  in,  601 

symptoms  of,  600 

temperature  in,  603 

treatment  of,  603 

vomiting  in,  601 
Infantile   paralysis    (see    Paralysis,  Acute 

Infantile  Spinal),  371 
Infants'  foods,  603 

general  management  of,  604 
Infection,  duration  of,  in  diphtheria,  90 

in  measles,  23 

in  mumps,  67 

in  scarlet  fever,  33 

in  small-pox,  55 

in  whooping-cough,  114 
Inflation  of  bowel  in  intussusception,  676 

of  lung  in  atelectasis,  461 
Inhalations,   antiseptic,   in   chronic   bron- 
chitis, 489 

in  diphtheria,  104 

in  fibroid  induration  of  lung,  480 

in  membranous  croup,  104 

in  whooping-cough,  136 
Injections,  aural,  189,  354 

intestmal,  638,  639,  653 

nasal,  105 

of  air  in  intussusception,  676 

of  ipecacuanha  in  colitis,  638 

of  nitrate  of  silver  in  ulceration  of  the 
bowels,  667 


Inspiration,  retraction  of  chest  in,  400 
Intelligence  in  chorea,  b03 

in  chronic  hydrocephalus,  343 

in  rickets,  141 

in  tumour  of  brain,  333 
Intermittent  fever  (see  Ague),  147 
Internal    convulsions     (see    Laryngismus 

Stridulus),  267 
Intertrigo  (see  Erythema  Intertrigo),  783 
Intestinal  worms  (see  Worms,  Intestinal), 

705 
Intestines,  catarrh  of,  624 

ulceration  of  (see  Bowels,  Ulceration 
of),  660 
Intussusception,  668 

bloody  stools  in,  670 

causation  of,  668 

colic  in,  670 

diagnosis  of,  673 

diet  in,  677 

duration  of,  673 

morbid  anatomy  of,  668 

prognosis  in,  675 

seat  of,  669 

sj'mptoms  of,  670 

temperature  in,  670 

tenesmus  in,  670 

treatment  of,  676 

tumour  of  abdomen  in,  673 

vomiting  in,  673 
Invagination  of  bowels    (see  Intussuscep- 
tion), 668 
Inward  fits,  279 

Iodine   in  treatment   of   amyloid    degen- 
eration, 733 

of  scrofula,  189 
Iodoform  in  treatment  of   aphthous  vul- 
vitis, 777 

of  gangrene  of  vulva,  171 

of  gangrenous  varicella,  50 
Ipecacuanha  in  treatment  of  bronchitis,  487 

of  catarrh  of  colon,  638 

of  dysentery,  65 1 

of  inflammatory  diarrhoea,  638 

of  tenesmus,  638 

of  vomiting,  639 
Ipecacuanha,  injections  of,  in  colitis,  638 
Irritative  fever,  10 
Itch  (see  Scabies),  798 

Jaborandi  in  treatment  of  uraemia,  47 
Jadelot's  lines,  7 
Jaundice,  714 

catarrhal,  614 
in  amyloid  liver,  733 
in  childhood,  719 
causes  of,  719 
treatment  of,  731 
in  croupous  pneumonia,  430 
in  hypertrophic  cirrhosis  of  liver,  738 
in  infancy  (see  Icterus  Neonatorum), 
714 
Jaws,  growth  of,  in  rickets,  138 

stiffness  of,  in  infantile  tetanus,  310 
in  retro-pharyngeal  abscess,  594 
Jejunum,  catarrh  of,  stools  in,  634 


828 


INDEX. 


Joints,    enlargement    of,   in  hgemophilia, 
244 

in  inherited  syphilis,  206 

in  rickets,  137 

in  scurvy,  256 
Joints,  looseness  of,  in  infantile  spinal  par- 
alysis, 377 

in  rickets,  138 
Joints,  rheumatio  inflammation  of,  155 
Joints,  rigidity  of,  in  cerebral   paralysis, 
377 

in  cerebro-spinal  fever,  69 

in  encephalitis,  351 

in  purulent  meningitis,  349 

ia  spasmodic  spinal  paralysis,  381 

in  tetanus,  310 

in  tetany,  274 

in  tubercular  meningitis,  360 

significance  of,  263 

K  AM  ALA  in  treatment  of  tape- worm,  713 
Keratitis,  scrofulous,  177 

syphilitic,  211 
Kidney,  calculus  of,  763 

alkalies  in  treatment  of,  768 
causation  of,  764 
diagnosis  of,  767 
diet  in,  768 
hsematuria  from,  765 
prognosis  in,  768 
pyelitis  from,  766 
renal  colic  from,  766 
symptoms  of,  764 
treatment  of,  768 
urine  in,  765 
Kidney,  dropsy  of  (see  Hydronephrosis),  773 
fatty,  the,  753 

diagnosis  of,  760 
treatment  of,  760 
granular,  the,  753 

symptoms  of,  755 
hsemorrhage   from   (see   Hasmaturia), 

746 
sarcoma  of,  770 

diagnosis  of,  773 
symptoms  of,  771 
tuberculosis  of,  193 
tumours  of,  770 

diagnosis  of,  773 
morbid  anatomy  of,  770 
treatment  of,  774 
Kidney,  the  amyloid,  753 
diagnosis  of,  760 
occasional  cure  of,  760 
symptoms  of,  757 
treatment  of,  760 

Bright' s  disease  of  (see  Bright's  Dis- 
ease), 752 
Knees,  pain  in,  in  spinal  caries,  178 

swelling  of,  in  hcemophilia,  242,  244 
Koumiss  iu  treatment  of  choleraic  diar- 
rhoea, 644 
of  inflammatory  diarrhoea,  636 

Labial  line,  significance  of,  7 

Lactic  acid,  formation  of,  in  rickets,  131 


Laryngismus  stridulus,  267 

ammonia  in  treatment  of,  272 

an    occasional  sequel    of    whooping- 
cough,  121 

asphyxia  in,  271 

association  of,  with  rickets,  267 

attacks  of,  269 

causation  of,  267 

chloral  in  treatment  of,  273 

cold  sponging  in  treatment  of,  272 

death  from,  270 

diagnosis  of,  271 

in  syphilitic  infants,  210 

incarceration  of  epiglottis  in,  271 

musk  in  treatment  of,  273 

prognosis  in,  272 

spasm  of  diaphragm  in,  270 

symptoms  of,  269 

temperature  in,  270 

treatment  of,  272 
Laryngitis,  chronic,  406 

causes  of,  496 

diagnosis  of,  409 

from  hysterical  aphonia,  409 

treatment  of,  411 
Laryngitis  in  epidemic  roseola,  30 

in  erysipelas,  110 

in  measles,  25 

in  small-pox,  59 

membranous   (see    Croup,    Membran- 
ous), 95 

simulated  by  anaemia  of  larynx,  409 
Laryngitis,  simple,  406 

calomel  in  treatment  of,  410 

causation  of,  406 

collapse  of  lung  from,  407 

death  from.  408 

diagnosis  of,  408 

duration  of,  408 

dyspnosa  in,  407 

from  scald,  407 

morbid  anatomy  of,  406 

prognosis  in,  410 

treatment  of,  410     • 
Laryngitis  stridulosa,  411 

albuminuria  in,  412 

at  onset  of  catarrhal  pneumonia,  439 
of  measles,  25 

causes  of,  41 1 

complications  of,  413 

diagnosis  of,  413 

from  laryngismus  stridulus,  271 
from  membranous  croup,  413 
from  oedema  of  glottis,  414  ' 
from    retro-pharyngeal     abscess, 
414     • 

dyspncea  in,  412 

morbid  anatomy  of,  411 

paroxysms  of,  412 

prognosis  in,  414 

symptoms  of,  412 

temperature  in,  412 

treatment  of,  414 
Laryngitis,  tubercular,  415 

causation  of,  415 

diagnosis  of,  417 


INDEX. 


829 


Laryngitis,  tubercular,  dyspnoea  in,  416 

husky  voice  in,  416 

prognosis  in,  418 

symptoms  of,  416 

treatment  of,  418 
Laryngoscope,  difficulty  of  using,  417 

value  of,  in  diagnosis,  36 
Larynx,  anasmia  of,  26,  409 

catarrh  of  (see  Laryngitis),  406 

external  pressure  on,  430 

impaction  of  foreign  body  in,  530 
Larynx,  oedema  of,  409 

diagnosis  of,  409,  414 

treatment  of,  410 
Larynx,  scald  of,  407 

spasm  of  (see  Laryngismus  Stridulus), 
367 

spasm  of,  in  whooping-cough,  118 
Larynx,  suppuration  about,  419 

aphonia  in,  430 

causes  of,  419 

death  from,  430 

diagnosis  of,  430 

from  retro-pharyngeal  abscess,  430 

diet  in,  431 

difficulty  of  swallowing  in,  430 

dyspnoea  from,  419 

hoarse  cough  in,  430 

orthopnoea  in,  430 

prognosis  in,  431 

stridulous  respiration  in,  430 

swelling  of  throat  in,  430 

symptoms  of,  419 

treatment  of,  431 
Larynx,  warty  growths  of,  417 
Latent  otitis,  348 

peritonitis,  688 

scarlatina,  40 
Leeches  in  treatment    of  acute  peritoni- 
tis, 691 

of  typhlitis,  684 
Leucocytes,  excess  of,  in  blood,  317 
Leucocythemia,  316 

alteration  of  blood  in,  817 

caiisation  of,  316 

complexion  in,  317 

diagnosis  of,  318 

enlargement  of  spleen  in,  317 

haemorrhages  in,  318 

morbid  anatomy  of,  216 

prognosis  in,  319 

pulse  in,  218 

symptoms  of,  217 

temperature  in,  318 

treatment  of,  219 
Ligaments,  looseness  of,  in  infantile  spinal 
paralysis,  377 

in  rickets,  140 
Lime,  hypophosphite  of,  in  treatment  of 

pulmonary  phthisis,  517 
Liver,  amyloid  degeneration  of,  731 

ansemia  in,  732 

causation  of,  731 

diagnosis  of,  732 

morbid  anatomy  of,  731 

prognosis  in,  733 


Liver,  amyloid  degeneration  of,  symptoms 
of,  731 

treatment  of,  733 
Liver,  cirrhosis  of,  726 

atrophic  form  of,  737 

diagnosis  of,  739 

hypertrophic  lorm  of,  738 

in  malformation  of  bile-ducts,  716 

in  tubercular  peritonitis,  694 

morbid  anatomy  of,  736 

prognosis  in,  739 

symptoms  of,  737 

treatment  of,  730 

two  forms  of,  726 
Liver,  congestion  of,  723 

causation  of,  722 

diagnosis  of,  733 

in  ague,  148 

treatment  of,  151 

in  rickets,  134 

morbid  anatomy  of,  733 

treatment  of,  734 
Liver,  displacement  of,  733 

examination  of,  12,  724 
Liver,   fatty  inffitration  of,  causation  of, 
735 

diagnosis  of,  736 

in  exhausting  disease,  735 

in  inflammatory  diarrhoea,  630 

in  leucocythemia,  217 

in  lymphadenoma,  223 

in  phthisis,  acute,  506 

chronic  tubercular,  511 

in  rickets,  134 

in  tuberculosis,  198 

morbid  anatomy  of,  735 

symptoms  of,  735 

treatment  of,  736 
Liver,  hydatid  of,  737 

causation  of,  737 

diagnosis  of,  740 

evacuation  of  fluid  in,  741 

morbid  anatomy  of,  737 

prognosis  in,  741 

suppuration  of  cyst  in,  739 

symptoms  of,  738 

treatment  of,  741 
Liver,  syphilitic  disease  of,  305 
inflammation  of,  718 

tuberculosis  of,  193 
Lividity  of  face  in  asthma,  bronchial,  531 

in  atelectasis,  congenital,  463 
post-natal,  467 

in  capillary  bronchitis,  484 

in  cardiac  dyspnoea,  98 

in  catarrhal  pneumonia,  437 

in  clotting  of  blood  in  heart,  550 

in  congenital  malformation  of  heart, 
538 

in  croupous  pneumonia,  425 

in  embarrassed  pulmonary  circulation, 
427 

in  enlarged  bronchial  glands,  183 

in  foreign  body  in  air-tubes,  537 

in  interstitial  oedema  of  lung,  39 

in  membranous  croup,  96 


830 


INDEX. 


Lividity  of  face  in  peritonitis,  687 

in  pleurisy,  449 

in  retro-pharynge^l  abscess,  593 

in  scald  of  glottis,  407 

in  stridulous  laryngitis,  413 

in  suppuration  about  larynx,  419 
Local  asphyxia,  167 
Long  round   worm   (see  Ascaris  Lumbri- 

coides),  705 
Lumbricus  (see  Ascaris  Lumbricoides),  705 
Lungs,  catarrh  of  (see  Catarrh,  Pulmon- 
ary), 481 

collapse  of  (see  Atelectasis),  461 

diseases  of,  399 

emphysema  of  (see  Emphysema,  Pul- 
monary), 491 

fibroid  induration  of  (see  Fibroid  In- 
duration of  Lung).  473 

gangrene  of  (see  Grangrene,  Pulmon- 
ary), 496 

syphilitic  disease  of,  205 
Lymph,  inoculation  of,  53 
Lymphadenoma,  220 

adenoid  growths  in,  222 

age  of  children  affected  by,  320 

auEemia  in,  227 

blood  in,  222 

causation  of,  220 

diagnosis  of,  227 

drowsiness  in,  224 

duration  of,  226 

dyspnoia  in,  226 

epistaxis  in.  226 

extirpation  of  growths  in,  328 

glandular  enlargement  in,  221 

kidneys  in,  223 

liver  in,  223 

morbid  anatomy  of,  220 

paralysis  in,  226 

phosphorus  in  treatment  of,  238 

spleen  in,  221 

symptoms  of,  222 

temperature  in,  224 

treatment  of.  227 

ulcerative  stomatitis  in,  334 

MAiiARiAL  fever  (see  Ague),  147 
Malignant  diphtheria,  97 

pustule,  diagnosis  of,  569 

scarlet  fever,  36 

small-pos,  60 
Malnutrition  (see  Infantile  Atrophy),  596 
Malt  extract  in  treatment  of  chronic  con- 
stipation, 632 

of  chronic  diarrhoea,  640 

of  rickets,  145 
Malted  bread.  666 

Marasmus  (see  Infantile  Atrophy),  596 
Measles   a   cause   of    valvular  disease   of 
heart,  544 

asthenic,  24 

bronchitis  in,  25 

catarrhal  pneumonia  in,  25 

chest  symptoms  in,  24 

complications  of,  25 

convulsions  in,  25 


Measles,  diagnosis  of,  26 

duration  of  infective  period  of,  22 

epistaxis  in,  25 

eruption  of,  23 

incubation  stage  of,  22 

morbid  anatomy  of,  22 

otitis  in,  25 

prognosis  in,  27 

relapse  of,  25 

sequelae  of,  26 

stridulous  laryngitis  in,  23 

symptoms  of,  22 

treatment  of,  28 
Megrim,  294 

causation  of,  294 

diagnosis  of,  296 

disorders  of  vision  in,  395 

headache  in.  295 

neuralgic  pains  in  limbs  in,  296 

pathology  of,  394 

pulse  in,  395 

symptoms  of,  395 

treatment  of,  397 

value  of  ergot  in  treatment  of,  297 
Melsena,  causes  of,  654 

diagnosis  of,  657 

in  atrophic  cirrhosis  of  liver,  728 

in  dysentery,  649 

in  enteric  fever,  78 

in  heemophilia,  243 

in  hfemorrhagic  purpura,  249 

in  infants,  654 

in  intussusception,  672 

in  polypus  of  rectum,  656 

in  ulceration  of  bowels,  663 

prognosis  in,  658 

spurious,  654 

causes  of,  654 
diagnosis  of,  657 

treatment  of,  659 
Meleena  neonatorum,  654 

causes  of,  654 

diagnosis  of,  657 

symptoms  of,  656 

treatment  of,  659 
Mellin's  food  in  artificial  feeding,  604 
Membrane,  false,  in  diphtheria,  92 
Meningeal  hsemorrhage  (see  Hsemorrhage, 

Meningeal),  324 
Meningitis,  basic,   in   syphilitic  children, 
211 

cerebro  -  spinal     (see     Cerebro  -  spinal 
Fever),  68 
Meningitis,  purulent,  346 

breathing  in,  349 

causation  of,  346 

convulsions  in,  349 

convulsive  form  of,  349 

diagnosis  of,  353 

duration  of,  349 

headache  in,  349 

morbid  anatomy  of,  347 

phrenitic  form  of,  350 

prognosis  in,  354 

stupor  in,  34P 

symptoms  of,  34& 


I]SrDEX, 


831 


Meningitis,  purulent,  temperature  in,  349 

treatment  of,  354 
Meningitis,    tubercular    (see    Tubercular 

Meningitis),  355 
Mercury  as  a  cause  of  anasmia,  231 

in  treatment  of  acute  dysentery,  G52 
of  inherited  syphilis,  214 
of  oedema  of  glottis  from  scald, 
410 
Mesenteric  glands,  enlargement  of,  183 

diagnosis  of,  184 

prognosis  in,  186 

signs  of  pressure  from,  184,  224 

symptoms  of,  184 

termination  of,  186 

treatment  of,  187 
Metastasis  of  mumps,  66 
Micturition,    painful,  from    uric    acid   in 
water,  765 

from  contracted  prepuce,  767 

in  vulvitis,  775 
Micrococci  in  croupous  pneumonia,  434 

in  diphtheria,  91 

in  erysipelas,  110 

in  stomatitis,  91 
Milk,  artificial  human,  606 

ass',  analysis  of,  597 

condensed,  605 

cow's,  analysis  of,  597 

cause  of  indigestibility  of,  597 
various  ways  of  preparing,  604 

goat's,  analysis  of,  597 

human,  analysis  of,  597 

occasional  indigestion  of,  599 

pancreatised,  606 

preserved,  danger  of,  606 
Miliaria  from  sweating,  136 
MoUuscum  contagiosum,  796 

diagnosis  of,  797 

morbid  anatomy  of,  796 

symptoms  of,  796 

treatment  of,  796 
Morphia,  hypodermic  injection  of,  in  chol- 
eraic diarrhoea,  645 

in  acute  peritonitis,  691 
Mouth,  examination  of,  13 
Movements,  cautious,  in  spinal  caries,  158 

ia  tubercular  peritonitis,  694 
Mucous  disease  after  whooping-cough,  121 
Mucous  flux  in  pertussis,  121 
Mucous  membrane,  sloughing  of,  in  dysen- 
tery, 649 

membrane,  syphilitic  disease  of,  204 
Mucous  patches  in  inherited  syphilis,  204 

in   inherited  syphilis,    treatment    of, 
315 
Mumps,  65 

deafness  from,  66 

diagnosis  of,  67 

facial  paralysis  from,  67 

infection,  duration  of,  67 

metastasis  of,  66 

morbid  anatomy  of,  65 

sequel  ("e  of,  66 

symptoms  of,  65 

temperature  of,  65,  66 


Mumps,  treatment  of,  67 
Murmurs,  cardiac,  from  valvular  disease 
of  the  heart,  549 
in  anaemia,  233 
in  chorea,  303 
Muscle,  atrophy  of,  after  chorea,  303 
in  chronic  hydrocephalus,  343 
in  rickets,  134 
Muscle,   morbid   changes   in,  in  infantile 
spinal  paralysis,  376 
in  pseudo-hypertrophic  paralysis,  384 
in  rickets,  184 
Muscles,  contraction  of,  in  infantile  spinal 
paralysis,  876 
in  pseudo-hypertrophic  paralysis,  386 
Muscles,  massage  of,  m  angemia,  235 
in  chorea,  806 
spasm  of,  in  spastic  spinal  paralysis, 
381 

Narcotics  a  cause  of  constipation  in  ba- 
bies, 617 
Nasal  diphtheria,  98 

treatment  of,  105 
Nasal  line,  significance  of,  7  « 

obstruction     in     inherited     syphilis, 
209 
Navel,  haemorrhage  from  the,  056,  717 
Neck,  stifPness  of,  in  caries  of  cervical  ver- 
tebrse,  178 

in  retro-pharyngeal  abscess,  592 

in  rheumatism,  159 
Necrosis,  strumous,  diagnosis  of,  212 
Nematode  worms,  705 
Nephritis,  acute  desquamative,  39 

acute  parenchymatous,  in  inflamma- 
tory diarrhoea,  030 
Nervous  system,  diseases  of,  260 

irritability  of,  in  infancy,  2 
in  rickets,  142 
Nettlerash  (see  Urticaria),  785 
Night  terrors,  cause  of,  121,  560 

treatment  of,  562 
Nipple,  position  of,  in  childhood,  551 
Nitrate  of  silver  in  chronic  diarrhoea,  641 

in  ulceration  of  bowels,  667 
Nodules,  fibroid,  in  acute  rheumatism,  160 
Noma  (see  Cancrum  Oris),  567 
Nose,  shape  of,  in  inherited  syphilis,  211 
Nutrition,  danger  of  sudden  arrest  of,  4 

dependence  of,  upon  just  selection  of 
food,  596 

functions  of  blood  in,  229 

in  anaemia,  229 

of  paralysed  limbs  in  infantile  spinal 
paralysis,  373 
Nystagmus,  causes  of,  361 

in  cerebro-spinal  fever,  70 

in  chronic  hydrocephalus,  343 

in  congenital  cataract,  361 

in  idiocy,  396 

in  tubercular  meningitis,  360 

in  tumour  of  brain,  361 

Oatmkat.  for  constipated  infants,  604,  631 
Obstniction  of  bowels,  causes  of,  668 


832 


INDEX. 


Occipital  headache  in  cerebellar  tumour, 
337 
in  spinal  caries,  178 
CEdema  from  cardiac  dilatation,  547 
in  ascites,  701 
in  ague,  149 
in  amyloid  disease,  733 
in  anaemia,  233 
in  Bright's  disease,  acute,  39 

chronic,  754 
in  chronic  diarrhoea,  634 
in  enlarged  bronchial  glands,  181 
mesenteric  glands,  184,  226 
spleen,  238 
in  fibroid  induration  of  lung,  477 
in  peri-typhlitis,  680 
in  sarcoma  of  kidney,  771 
in  scarlet  fever,  39 
in  suppurative  pericarditis,  157 
interstitial,  of  lung,  39 
of  brain  in  chronic  hydrocephalus,  343 
(Edema  of  legs  from  enlarged  glands  in 
abdomen,  184,  226 
in  acute  tuberculosis,  195 
•        in  amyloid  liver,  732 

in  chronic  valvular  disease  of  heart, 

547 
in  congenital  heart  disease,  538 
in  dysentery,  649 
in  leucocythemia,  218 
in  purpura,  250 
in  tubercular  peritoniiis,  696 
CEdema  of  new-born  infants,  808 
diagnosis  of,  808 
treatment  of,  809 
Oidium  albicans  in  thrush,  573 

seat  of,  572 
Oil,  external  application  of,  18 
Oligsemia,  331 

Ophthalmoscopic  examination  in  chronic 
hydrocephalus,  343 
in  tubercular  meningitis,  359 
in  tumour  of  brain,  882 
Opisthotonos  in  infantile  tetanus,  310 
Opium  in  treatment  of  dysentery,  651 

of  inflammatory  diarrhoea,  638 
Opium,  susceptibility  to,  in  early  life,  18 
Optic  neuritis  in  chronic  Bright's  disease, 
755 
in  chronic  hydrocephalus,  343 
in  idiopathic  ansemia,  233 
in  tubercular  meningitis,  359 
in  tumour  of  brain,  333,  338 
Orange  juice  in  treatment  of  scurvy,  358 
Orthopncea  as  a  sign  of  external  pressure 
on  larynx,  430 
in  catarrhal  pneumonia,  437 
in  retropharyngeal  abscess,  592 
Ossification  in  rickets,  132 

of  skull  in  chronic  hydrocephalus,  341 
in  cretinism,  393 
Osteochondritis,  syphilitic,  306 
Osteomalacia  and  rickets,  135 
Otitis,  345 

acute,  symptoms  of,  348 

caries  of  petrous  bone  from,  368 


Otitis,  causes  of,  845 

chronic,  symptoms  of,  348 

consequences  of,  347,  368 

diagnosis  of,  353 

earache  from,  348 

facial  paralysis  from,  368 

from  follicular  pharyngitis,  579 

from  teething,  560 

in  measles,  35 

in  scarlet  fever,  40 

in  small -pox,  59 

latent,  348 

morbid  anatomy  of,  347 

prognosis  in,  354 

treatment  of,  189,  354 
Otorrhoea,  chronic,  treatment  of,  189,  354 
Oxalate  of  lime  calculi,  764 
Oxalate  of  lime  in  urine  in  cases  of  ic- 
terus neonatorum,  716 

in  urine  of  rickety  children,  134 
Oxyuris  vermicularis,  705 

description  of,  705 

seat  of,  705 

symptoms  of,  709 

treatment  of,  711 

Pain  in  chest  from  foreign  body  in  air- 
tubes,  538 

from  spinal  caries,  178 
Paint,  white,  as  an  application  in  erysip- 
elas, 113 
Palate,  the  V-shaped,  in  idiocy,  396 
Palpation  of  chest,  401 
Palpitation,  cardiac,  in  anaemia,  333 

in  cyanosis,  538 
Pancreas,  secretion  of,   deficient  in  early 

infancy,  598 
Pancreatised  milk,  606 
Paracentesis  thoracis,  457 
Paralysis,  acute  infantile  spinal,  371 

causation  of,  371 

club-foot  in,  376 

complete  recovery  from,  374 

contraction  of  limbs  in,  376 

diagnosis  of,  377 

diet  in,  378 

electricity,  value  of,  in,  378 

genu  recurvatum  in,  376 

influence  of  teething  on,  371 

mode  of  production  of  contractions  in, 
375 

morbid  anatomy  of,  373 

partial  recovery  in,  374 

prognosis  in,  377 

retarded  growth  of  bone  in,  373 

stage  of  contraction  in,  375 

state  of  muscles  in,  373 

sudden  onset  of,  373 

symptoms  of,  373 

test  of  possible  recovery  in,  377 

treatment  of,  378 

warmth,  value  of,  in,  378 
Paralysis,  cerebral,  diagnosis  of,  377 
Paralysis,  diphtheritic,  99 

diagnosis  of,  100 

pathology  of,  93 


INDEX. 


833 


Paralysis,  diphtheritic,  prognosis  in,  103 

symptoms  of,  99 

treatment  of,  107 
Paralysis  from  haemorrhage  into  cord,  377 

from    pressure  of  growths  on    cord, 
226 

hysterical,  265 
Paralysis  of  diaphragm,  100 
diagnosis  of,  102 

of  face,  367 

of  gullet,  100 

of  heart,  99 

of  limbs  from  diphtheria,  100 

of  pharynx,  100 

of  portio  dura,  367 

of  soft  palate,  368 

of  tongue  and  lips,  100 
Paralysis,  pseudo-hypertrophic,  384 

atrophy  of  muscle  in,  386 

causation  of,  384 

contraction  of  muscle  in,  386 

course  of,  387 

diagnosis  of,  387 

duration  of,  387 

hypertrophy  of  muscle  in,  384,  385 

morbid  anatoiny  of,  384 

prognosis  in,  388 

symptoms  of,  385 

temperature  in,  386 

treatment  of,  388 

weakness  of  muscles  in,  385 
Paralysis,  spasmodic  spinal,  380 

causation  of,  381 

contractions  in,  382 

diagnosis  of,  382 
I         difficulty  of  walking  in,  381 

morbid  anatomy  of,  381 

often  congenital,  381 

peculiarity  of  gait  in,  382 

rigidity  of  joints  in,  381 

symptoms  of,  381 

treatment  of,  382 
Paralysis,  syphilitic,  of  arms,  210 

temporary,  at  onset  of  small-pox,  56 
Parasitic  skin  diseases,  798 
Parotiditis  (see  Mumps),  65 
Paroxysm  of  whooping-cough,  description 

of,  116 
Paroxysmal  dyspnoea  (see  Dyspnoea,  Par- 
oxysmal), 519 
Pelvis,  deformity  of,  in  rickets,  139 
Pemphigus,  779 
Pepsin  for  habitual  constipation,  622 

in  treatment  of  chronic  diarrhcea,  640 
Percussion  of  chest,  402 
Perforation  of  bowel  in  enteric  fever,  81 

in  peri-typhlitis,  679 
Pericarditis,  rheumatic,  155 

auscultatory  signs  of,  156 

cerebral  symptoms  in,  159 

diagnosis  of,  161 

iodide  of  potassium  in,  165 

morbid  anatomy  of,  154 

physical  signs  of,  156 

symptoms  of,  155 

treatment  of,  165 
53 


Pericarditis,  suppurative,  157 

diagnosis  of,  162 

oedema  of  legs  in,  157 

physical  signs  of,  157 

symptoms  of,  1 57 

temperature  in,  157 

treatment  of,  165 
Pericardium,  adhesion  of,  546,  550 
Periosteogenesis,  syphilitic,  206 
Peritonitis,  acute,  ascites  in,  687 

causation  of,  685 

diagnosis  of,  689 

from  perforation  of  bowel,  688 

in  erysipelas,  111,  686 

latent  form  of,  688 

morbid  anatomy  of,  686 

pains  in,  687 

prognosis  in,  691 

secondary,  688 

to  pleurisy,  453 

symptoms  of,  686 

temperature  in,  687 

treatment  of,  691 

vomiting  in,  687 
Peritonitis,  tubercular,  693 

acute  form  of,  696 

diagnosis  of,  697 

diet  in,  699 

insidious  beginning  of,  694 

morbid  anatomy  of,  693 

prognosis  in,  698 

shape  of  belly  in,  695 

symptoms  of,  694 

temperature  in,  696 

tenderness  of  belly  in,  694 

treatment  of,  698 
Peri-typhlitis,  678 

causation  of,  678 

diagnosis  of,  683 

morbid  anatomy  of,  678 

prognosis  in,  683 

simulation  of  hip-joint  disease  by,  680 

suppuration  in,  680 

symptoms  of,  679 

treatment  of,  684 
Peroxyde  of  hydrogen    in    treatment   of 

cyanosis,  543 
Pertussis  (see  Whooping-cough),  109 
Petechise   from   embolisms   in   cutaneous 
vessels,  158,  552 

in  anemia,  233 

in  asthenic  measles,  24 

in  atrophic  cirrhosis  of  liver.  728 

in  cerebro-spinal  fever,  69,  10 

in  hsemoiihilia,  243 

in  hypertrophic  cirrhosis  of  liver,  729 

in  lymphadenoma,  224 

in  malformation  of  bile-ducts,  717 

in  malisrnant  diphtheria,  97 
small-pox.  60 

in  melffina  neonatorum,  656 

in  purpura,  248 

in  scurvy,  256 

in  ulcerative  endocarditis,  158 

in  umbilical  phlebitis,  719 
Petrous  bone,  caries  of,  368,  540 


834 


INDEX. 


Pharyngitis,  catarrhal,  576 

caiisation  of,  576 

diagnosis  of,  577 

syroptoms  of,  576 

treatment  of,  577    . 
Pharyngitis,  follicular,  578 

causation  of,  578 

cauterisation  in,  580 

deafness  in,  579 

diagnosis  of,  579 

morbid  anatomy  of,  578 

prognosis  in,  579 

symptoms  of,  578 

treatment  of,  579 
Pharyngitis,  herpetic,  580 

causation  of,  580 

diagijosis  of,  580 

symptoms  of,  580 

treatment  of,  581 
Pharyngitis,  tubercular,  581 

diagnosis  of,  582 

morbid  anatomy  of,  581 

prognosis  in.  583 

symptoms  of,  581 

treatment  of,  583 
Pharynx,  paralysis  of,  100 
Pharynx,  scald  of,  576 

symptoms  of,  577 

treatment  of,  578 
Phthisis,  acute,  505 

diagnosis  of,  507 

dyspnoea  in,  506 

physical  signs  of,  506 

prognosis  in.  508 

symptoms  of,  505 

temperature  in.  506 

treatment  of,  516 

wasting  in,  506 
Phthisis,  chronic  pneumonic,  508 

cough  in,  509 

diagnosis  of,  513 

physical  signs  of,  509,  510 

prognosis  in,  515 

secondary  catarrhal  pneumonia  in,  510 

symptoms  of,  508 

temperature  in,  510 

treatment  of,  516 
Phthisis,  chronic  tubercular,  511 

diagnosis  of,  513 

prognosis  in,  515 

symptoms  of,  511 

treatment  of,  516 
Phthisis,  pulmonary,  503 

causation  of,  503 

morbid  anatomy  of,  504 

treatment  of,  516 

varieties  of,  503 
Phthisis  simulated  by  attacks  of  recurang 
catarrh,  483,  611 

tuberculo-pneumonic,  511 
Pigeon- breast  from  permanent  collapse  of 
lower  lobes  of  lungs,  400 

in  rickets.  139 
PittinsT  of  skin  after  varicella,  49 

after  variola,  59 
Pleurisy,  444 


Pleurisy,  aspiration  of  fluid  in,  457 

causation  of,  444 

characters  of  effusion  in,  444 

complexion  in,  446 

complications  of,  453 

diagnosis  of,  453 

diaphragmat  c,  453 

diet  in,  457 

exaggerated  symptoms  in,  449 

friction-sound  in,  449 

loculated.  452 

morbid  anatomy  of,  444 

often  conjoined  with  pericarditis,  158 

onset  of,  445 

pain  in.  446 

perforation  of  bronchus  in,  450 
of  chest-wall  in,  450 

physical  signs  of,  447 

plastic,  453 

prognosis  in,  455 

resection  of  rib  in,  460 

rheumatic,  158 

spontaneous  evacuation   of    fluid  in, 
450 

sudden  death  in,  458 

symptoms  of,  445 

temperature  ia.  446 

terminations  of,  449 

treatment  of,  456 

tuberculous,  453 

use  of  drainage-tube  in,  459 

varieties  of,  451 
Pneumonia,  catarrhal,  434 

breathing  in,  437 

causation  of.  434 

complications  of,  439 

cough  in.  437 

counter- Irritation  in,  443 

diagnosis  of.  439 

diet  in,  443 

dilated  bronchi  in,  439 
diagnosis  of,  441 

dyspnoea  in.  437 

favourable  ending  in,  438 

in  diphtheria,  98 

in  measles,  35 

in  pulmonary  tuberculosis,  196 

in  whooping-cough,  130 

iron  in  treatment  of,  443 

mode  of  death  in,  438 

morbid  anatomy  of,  434 

physical  signs  of,  437 

prognosis  in,  441 

pulse-respiration  ratio  in,  437 

stimulants  in  treatment  of,  443 

subacute  course  of,  438 

symptoms  of,  436 

temperature  in,  436 

tepid  baths  in  treatment  of,  441 

treatment  of,  441 
Pneumonia,  cerebral,  863,  435 
Pneumonia,  croupous,  423 

abscess  of  lung  in,  429 

bleeding,  occasional  value  of,  in,  433 

breathing  in,  436 
causation  of,  432 


INDEX. 


835 


Pneumonia,  croupous, complications  of,  430 

crisis  of,  429 

delirium  in,  425 

diagnosis  of,  430 

diet  in,  483 

facias  of,  425 

headache  in,  425 

jaundice  in,  430 

latent,  429 

morbid  anatomy  of,  423 

muscular  weakness  in,  425 

nature  of,  422 

nervous  symptoms  in,  425 

•occasional  alarming  symptoms  in,  427 

onset  of,  424 

physical  signs  of,  427 

prognosis  in,  481 

pulse-respiration  ratio  in,  426 

quinine  in  treatment  of,  432 

reduction  of  pyrexia  in,  482 

stimulants,  indication  for,  in,  433 

symptoms  of,  424 

temperature  in,  427 

terminations  of,  428 

treatment  of,  532 

urine  in,  426 
Pneumo-thorax    from    rupture   in   inter- 
lobular emphysema,  492 

from  rupture  in  pulmonary  gangrene, 
499 
Portio  dura,  paralysis  of,  367 

causes  of,  367 

deafness  in.  370 

diagnosis  of,  369 

flattening  of  arch  of  palate  in,  368 

from  neglected  otitis,  368 

impairment  of  taste  in,  368 

inability  to  whistle  in,  368 

otorrhoea  in,  370 

prognosis  in,  369 

symptoms  of,  368 

treatment  of,  370 
Potash,  chlorate  of,  in  treatment  of  ulcer- 
ative stomatitis,  566 
Prolai^se  of  rectum  from  straining  in  mic- 
turition, 748 
Prophylaxis  in  scarlet  fever,  43 
Prurigo,  778 
Psoriasis,  780 
Puerperal  erysipelas,  109 
Pulse  during  sleep  in  infants,  9 

in  acquired  hydrocephalus,  344 

in  aortic  regurgitant  disease  not  char- 
acteristic, 550 

in  atrophic  cirrhosis  of  liver,  729 

in  capillary  bronchitis,  484 

in  cerebral  haemorrhage,  327 
tumour,  338 

in  cerebro-spinal  fever,  71 

in  congenital  heart  disease,  538 

in  diphtheria,  102 

in  encei)halitis,  351 

in  enteric  fever,  79 

in  gangrene  of  lung,  498 

in  infants,  9 

in  inflammatory  diarrhoea,  631 


Pulse  in  intussusception,  673 

in  leucocythemia,  218 

in  measles,  24 

in  megrim,  295 

in  oedema  of  new-bom  infants,  808 

in  peritonitis,  acute,  687 

in  peri-typhlitis,  680 

in  pneumonia,  catarrhal,  437 
croupous,  426 
tuberculous,  197 

in  purulent  meningitis,  349 

in  scarlet  fever,  34 

in  sclerema,  807 

in  spasm  of  pertussis,  116 

in  spurious  hydrocephalus,  632 

in  tetanus,  312 

in  tubercular  meningitis,  359,  361 

slow,  as  indicating  cardiac  failure,  99 

slow,  in  convalescence  from  acute  (lis. 
ease,  265 

slow,  significance  of,  265 
Pulse-respiration  ratio  in  capillary   bron- 
chitis, 488 

in  catarrhal  pneumonia,  437 

in  collapse  of  lung,  467 

in  croupous  pneumonia,  426 

in  pleurisy,  453 
Pupils  in  acquired  hydrocephalus,  344 

in  purulent  menmgitis,  849 

in  tubercular  meningitis,  859 

inequality  of,  significance  of,  261 
Purgatives,  abuse  of,  19 
Purgatives,  value  of,  in  acute  Bright's  dis- 
ease,  46 

in  anaemia.  234 

in  chronic  Bright's  disease,  761 

in  quinsy,  589 

in  valvular  disease  of  heart,  553 
Purpura,  247 

auEemia  in,  250 

aperients  for,  252 

causation  of,  247 

cerebral  hemorrhage  in,  251 

convulsions  in,  251 

diagnosis  of,  251 

eruption  of,  248 

hsemorrhagica,  249 

heart  murmur  in,  250 

in  chronic  Bright's  disease,  755 

morbid  anatomy  of,  247 

CBdema  in,  249 

pains  in  limbs  in,  249 

pathology  of,  248 

prognosis  of,  251 

rheumatica,  249 

simplex,  248 

symptoms  of,  248 

temperature  in,  250 

treatment  of,  251 
Pyelitis  from  calculus  of  kidney,  766 
Pylocarpine  in  treatment  of  chronic  bron 
chitis,  489 

in  treatment  of  ursemia,  47 
Pyrexia  (see  Temperature) 

from   catarrh  in  scrofulous  children, 
177 


836 


IISTDEX. 


Pyrexia  from  entrance  of  organic  particles 
into  circulation,  552 
from  rapid  growth,  11 
of  teething,  558 
secondary  in  enteric  fever,  83 
in  small-pox,  58 

Quinine,  hypodermic  injection  of,  in  ague, 
151 

in  treatment  of  croupous  pneumonia, 

in  treatment  of  whooping-cough,  135 
large  doses  of,  for  acute  eczema,  795 
for  chronic  urticaria,  786 
Quinsy,  causation  of,  584 
deafness  from,  585 
diagnosis  of,  588 
morbid  anatomy  of,  585 
nasal  quality  of  voice  in,  585 
non-suppurative  form  of,  586 
prognosis  in,  588 
prostration  in,  586 
symptoms  of,  585 
temperature  in,  585 
treatment  of,  588 

Rash,  bromide,  298 

of  acute  tuberculosis,  195 

of  belladonna,  783 

of  cerebro-spinal  fever,  70 

of  chicken-pox,  48 

of  dentition,  560 

of  eczema,  790 

of  enteric  fever,  77 

of  epidemic  roseola,  30 

of  erysipelas,  110 

of  erythema,  783 

of  infantile  syphilis,  309 

of  measles,  23 

of  purpura,  248 

of  roseola,  787 

of  scarlet  fever,  34 

of  small-pox,  57 

of  teething,  560 

of  urticaria,  785 

of  varioloid,  61 
Raw  meat  in  treatment  of  chronic  diar- 
rhoea, 640 

mutton  juice,  258 
Rectum,  polypus  of,  656 

diagnosis  of,  658 

symptoms  of,  657 

treatment  of,  659 
Rectum,   prolapse   of,   from  straining    at 
stool,  619 

from  worms,  709 

in  diarrhoea,  682 

treatment  of,  689 

in  passing  water.  197 
Reflex  convulsions,  277 
Relapse  of  enteric  fever,  83 
of  infantile  syphilis,  311 
of  measles.  85 
of  rheumatic  fever,  155 
of  stridulous  laryngitis,  411 
Remedies,  internal,  18 


Renal  inadequacy,  758 

after  enteric  fever,  83 
treatment  of,  760 
Resonance,  vocal,  value  of,  405 
Respiration,  frequency  of,  in  infancy  (see 

Breathing),  110 
Respiratory  movements  in  the  infant,  13 
Retention  of  urine  in  enteric  fever,  78 

in  tubercular  meningitis.  359 
Retraction  of  head  (see  Head,  Retraction 

of) 
Retro-pharyngeal  abscess,  591 

acute  form  of,  593 

causation  of,  591 

chronic  form  of,  593 

cough  in,  593 

diagnosis  of,  594 

from  membranous  croup,  594 
from  oedema  of  glottis,  594    • 

duration  of,  598 

dysphagia  in,  593 

prognosis  in,  595 

stiffness  of  neck  in,  593 

swelling  of  neck  in,  598 

symptoms  of,  593 

treatment  of,  595 

tumour  of  pharynx  in,  593 

voice  in,  598 
Rheumatism,  acute,  158 

causation  of,  153 

cerebral  symptoms  in,  159 

chronic,  160 

consequences  of,  163 

convulsions  in,  159 

delirium  in.  159 

diagnosis  of,  161 

diet  in,  164 

duration  of,  160 

endocarditis  in,  158 

fibroid  nodules  in,  160 

heart  affection  in,  155 

joint  affection  in,  155 

morbid  anatomy  of,  154 

muscular,  treatment  of,  165 

of  abdominal  muscles,  159 

pericarditis  in,  155 

pneumonia  in,  159 

prognosis  in.  163 

relapses  in,  160 

salicylate  of  soda  in  treatment  of,  163 

symptoms  of.  154 

temperature  in,  154 

torticollis  in,  159 

treatiTient  of,  163 
Rheumatism,  scarlatinous,  38 

treatment  of,  46 
Ribs,  beading  of,  in  rickets,  139 

resection  of,  in  pleurisy,  460 

thinning  of.  in  scurvy,  354 
Rigidity  of  joints  (see  Joints,  Rigidity  of) 
Ringworm.  801 

of  the  scalp  (see  Tinea  Tonsurans),  799 
Roseola,  786 

diagnosis  of,  786 

epidemic  (see  Epidemic  Roseola),  30 

symptoms  of,  785 


INDEX. 


837 


Roseola,  treatment  of,  786 
Eotheln  (see  Epidemic  Roseola),  30 
Roundworm  (see  Ascaris  Lumbricoides)  705 

Salicylate  of  soda  in  treatment  of  acute 
rheumatism,  163 
in  treatment  of  quinsy,  588 
Saliva,  scanty  secretion  of,   in   early  in- 
fancy, 598 
value  of,  in  digestion,  598 
Sand,  uric  acid,  in  urine,  757,  760,  763 
Scabies,  798 

diagnosis  of,  799 
symptoms  of,  798 
treatment  of,  799 
Scald  of  larynx,  407 
of  pharynx,  576 
Scarlet  fever,  33 
abscesses  in,  40 
albuminuria  in,  39 
complications  of,  37 
coryza  of,  38 
diagnosis  of,  41 
diarrhcsa  in,  38 
diphtheria  in  course  of,  38 
duration  of  infective  period  of,  32 
gangrene  in,  40 

infective  period,  duration  of,  in,  32 
latent,  40 
malignant,  36 
morbid  anatomy  of,  33 
nephritis,  albuminous,  after,  39 
nervous  symptoms  of,  36 
oedema  in,  39 
otorrhoea  in,  40 
prognosis  of,  41 
rash  of,  34 
rheumatism  in,  38 
stage  of  desquamation  of,  36 
of  eruption  of,  34 
of  incubation  of,  38 
of  invasion  of,  34 
symptoms  of,  33 
temperature  in,  34,  35 
throat  affection  in,  35,  37 
treatment  of,  43 
urseraia  in,  39 
urine  in,  39 
varieties  of,  34 
Sclerema,  806 
adiposa,  806 
duration  of,  808 
morbid  anatomy  of,  806 
symptoms  of,  807 
temperature  in,  807 
treatment  of,  809 
Scolices  of  taenia  echinococcus,  738 
Scrofula,  173 

bone  disease  in,  178 

bronchial  glands,  caseation  of,  180 

causation  of,  173 

climate  in  treatment  of,  187 

cold  bathing  in  treatment  of,  188 

cutaneous  abscesses  in,  177 

deafness  from,  177 

diagnosis  of,  185 


Scrofula,  diet  in,  187 

glandular  lesions  in,  175,  179 
mesenteric  glands,  caseation  of,  183 
morbid  anatomy  of,  174 
otorrh(Ba  in,  177 

treatment  of,  189 
ozEena  in,  177 
pharyngeal  catarrh  in,  177 
prognosis  in,  186 
pulmonary  catarrh  in,  177 
skin  affections  in,  177 
spine,  disease  of,  in,  178 
symptoms  of,  175 
tendency  to  catarrh  in,  176 
treatment  of,  187 
Scurvy,  253 

anasmia  in,  256 
causation  of,  258 
connection  of,  with  rickets,  253 
diagnosis  of,  257 
gums  in,  256 
morbid  anatomy  of,  254 
orange  juice  in  treatment  cf,  258 
pathology  of,  255 
prognosis  in,  258 
separation  of  epiphyses  in,  256 
swelling  of  limbs  in,  256 
symptoms  of,  255 
temperature  in,  257 
tenderness  in,  256 
treatment  of,  258 
Seat-worm  (see  Oxyuris  Vermicularis),  705 
Secondary  pyrexia  in  enteric  fever,  82 

in  small-pox,  58 
Senses,   development   of,    in    healthy    in- 
fancy, 395 
dulness  of,  in  idiocy,  394 
in  lymphadenoma,  224 
Sewer-gas  a  cause  of  croupous  pneumonia, 
423 
of  diphtheria,  90 
of  enteric  fever,  74 
of  inflammatory  diarrhoea,  629 
of  quinsy,  584 
Sight,  impairment  of,  in  Bright's  disease, 
755 
in  cerebral  disease,  261 
in  cerebral  tumour,  332 
in  chronic  hydrocephalus,  343 
in  idiocy,  394 
Silver,  nitrate  of,  in  treatment  of  chronic 

diarrhoea,  641 
Skin,  diseases  of,  778 

dryness  of.  in  cyanosis,  539 

in  infantile  atrophy,  600 
earthy  tint  of,  in  atrophic  cirrhosis  of 

liver,  728 
earthy  tint  of,  in  chronic  abdominal 
derangement,  11 
Skin,  harshness  of,  in  acute  tuberculosis, 
195 
in  atrophic  cirrhosis  of  liver,  728 
in  chorea,  305 
in  cyanosis,  539 
in  lymphadenoma,  224 
in  renal  disease,  759 


838 


IjS^DEX. 


Skin,  harshness   df,  in  cirrhosis  of  liver, 
728 

in  cretinism,  396 
inelasticity  of,  in  renal  disease,  11,  759 
in  severe  thrush,  573 
in  syphilitic  infants,  211 
in  tuberculosis.  195 
staining  of,  after  birth,  714 
Skull,  auscultation  of,  in  rickets,  138 
Skull,  shape  of,  in  chronic  hydrocephalus, 
343 
in  idiocy,  396 
in  rickets,  137 
in  infantile  syphilis,  208 
Small-pox,  55 

complications  of,  59 
confluent,  60 
diagnosis  of,  61 
discrete,  6U 

duration  of  infection  in,  55 
malignant,  60 
modified,  61 
morbid  anatomy  of,  55 
papular  stage  of,  57 
prognosis  in,  62 
pustular  stage  of,  57 
secondary  fever  in,  58 
stage  of  decline,  58 
of  eruption,  56 
of  invasion,  56 
of  maturation,  57 
symptoms  of.  56 
temperature  in,  56,  58,  61 
treatment  of,  62 
varieties  of.  60 
varioloid,  61 
vesicular  stage,  57 
Snoring  from  enlarged  tonsils,  587 

from  paralysis  of  soft  palate,  100 
Snuffling  in  inherited  syphilis,  209 
Softening  of  caseous  glands,  175 
Sore  throat  in  diphtheria,  93 
in  enteric  fever,  78 
in  follicular  pharyngitis,  578 
in  herpes  of  the  pharynx,  580 
in  measles,  22 
in  mumps,  66 
in  quinsy,  585 
in  scarlet  fever,  34,  37 
in  tubercular  pharyngitis,  581 
Sounds,  breath-,  conducted  by  chest-wall, 

404 
Spasm   of  larynx  (see  Laryngismus  Stri- 
dulus), 411 
in  whooping-cough,  118 
Spasmodic  laryngitis  (see  Laryngitis  Stri- 

dulosa),  411 
Spinal  cord,  hsemorrhage  into.  377 
in  infantile  spinal  paralysis,  380 
in  tetanus,  309 
Spinal  paralysis,  infantile    (see  Paralysis, 
Infantile  Spinal),  371 
spasmodic   (see  Paralysis,   Spasmodic 
Spinal),  380 
Spine,  caries  of,  178 
attitudes  in,  178 


Spine,  caries  of,  diagnosis  of,  185 

pain  in  chest  from,  178 

stiffness  in  back  from,  178 

symptoms  of,  178 
Spine,  deformity  of,  in  rickets,  139 

ether  spray  to,  in  treatment  of  chorea, 
306 
Spleen,  chronic  congestion  of,  134 

embolism  of,  158,  287 
Spleen,  enlargement  of,  237 

causes  of,  237 

in  ague,  148 

in  atrophic  cirrhosis  of  liver,  728 

in  congenital  heart  disease,  539 

in   congenital   malformation   of  bile- 
ducts,  717 

in  rickets,  133 
Spleen,  extirpation  of,  219 

faradisation  of,  219 

in  leucocythemia,  216 

in  lymphadenoma,  221 

mode  of  examining,  237 
Spleen,  simple  hypertrophy  of,  238 

aneemia  in,  238 

blood  in,  characters  of,  238 

clothing  in,  241 

complexion  in.  238 

diagnosis  of,  240 

epistaxis  in,  238 

morbid  anatomy  of,  238 

oedema  in,  238 

perverted  appetite  in,  288 

petechisB  in,  238 

prognosis  in,  240 

symptoms  of,  238 

treatment  of,  240 
Spleen,  syphilitic  disease  of,  205 

tubercular  disease  of,  193 
Spotted  fever  (see  Cerebro  spinal  Fever), 68 
Sprays,  antiseptic,  in  diphtheria,  104 

in  gangrene  of  lung,  500 

in  pulmonary  phthisis,  518 

in  whooping-cough,  126 
Sprays,  ether,  to  spine  in  treatment  of  cho- 
rea, 306 
Squint  following  convulsions,  261 

from  hypermetropia,  261 

from  pressure   on   third  nerve,  226, 
332 

in  cerebral  paralysis.  377 

in  cerebro-spinal  fever,  71 

in  chronic  hydrocephalus,  343 

in  diphtheria,  100 

in  encephalitis,  351 

in  purulent  meningitis,  349 

in  tubercular  meningitis,  359 

in  tumour  of  brain,  332 

significance  of,  261 
Staggering  gait  in  cerebellar  tumour,  337 
Starch,  difficulty  of  digesting,  in  chronic 
diarrhoea,  640 

in  infancy,  596 

in  rickets,  145 
Steam-draught  inhaler.  Dr.  Lee's,  126 
Stethoscope,  value  of,  403 
Stimulants,  value  of,  18 


INDEX. 


839 


Stomach -tube   for  forced   feeding   of   in- 
fants, 15 
Stomatitis,  aphthous,  563 

causation  of,  5ii3 

diagnosis  of,  564 

prognosis  in,  564 

symptoms  of,  563 

temperature  in,  564 

treatment  of,  564 
Stomatitis,  gangrenous,  567 

causation  of,  567 

diagnosis  of,  569 

diet  in,  569 

disinfectants  in  treatment  of,  570 

morbid  anatomy  of,  567 

prognosis  in,  569 

stimulants  in  treatment  of,  569 

symptoms  of,  568 

treatment  of,  569 
Stomatitis,  simple,  559 
Stomatitis,  ulcerative,  564 

causation  of,  564 

chlorate  of  potash  in  treatment  of,  566 

diagnosis  of,  566 

diet  in,  566    . 

duration  of,  565 

in  lymphadenoma,  224 

local  applications  for,  566 

prognosis  in,  566 

symptoms  of,  565 

temperature  in,  565 

treatment  of,  566 
Stools,  appearance  of,  in  choleraic  diar- 
rhoea, 643 

in  chronic  diarrhoea,  633 

in  congestion  of  liver,  733 

in  dysentery,  649,  650 

in  inflammatory  diarrhoea,  631 

in  simple  diarrhoea.  626 

in  tubercular  peritonitis,  696 

in  ulceration  of  bowels,  662 
Stridor,    respiratory,    from    pressure    on 

trachea,  183 
Strophulus,  779 
Stupor  at  the  onset  of  small-pox,  56 

from  hyper-pyrexia  in  acute  rheuma- 
tism, 159 

from  indigestion,  3 

in  acquired  hydrocephalus,  344 

in  ague,  149 

in  asthenic  measles,  34 

in  Bright' s  disease,  acute,  39 
chronic,  755 

in  cerebro-spinal  fever,  69 

in  congestion  of  brain,  318 

in  convulsions,  380 

in  encephalitis,  351 

in  epilepsy,  388 

in  haemorrhage  into  brain,  324 

in  hypertrophic  cirrhosis  of  liver,  739 

in  malignant  diphtheria,  97 
scarlet  fever,  36 
small-pox,  60 

in  purulent  meningitis,  349 

in  tubercular  meningitis,  360 

in  umbilical  phlebitis,  719 


Stupor  in  urcemia,  39 

significance  of,  263 
Swallowing  difficult  in  infantile  tetanus, 
310 
in  post-natal  atelectasis,  476 
in  retro-pharyngeal  abscess,  593 
in  suppuration  about  larynx,  419 
Swallowing,  loss  of  power  in,  in  diphthe- 
ria, 94 
painful  in  diphtheria,  94 

in  follicular  pharyngitis,  578 
in  quinsy,  586 

in  tabercular  pharyngitis,  583 
peculiarities  of,  in  idiocy,  396 
Sweating  of  head  in  rickets,  138 

treatment  of,  145 
Syncope,  diagnosis  of,  from  epilepsy,  390 
from  flatulent  distention,  131,  613 
in  anasmia,  233 

in  congenital  heart  disease,  539 
in  chronic  valvular  disease  of  heart, 

547 
in  purpura  hsemorrhagica,  351 
Syphilis  conveyed  by  vaccination,  54 
Syphilis,  infantile,  303 

affection  of  bones  in,  306 
of  glottis  in,  304 
of  heart  in,  305 
of  liver  in,  205 
of  lungs  in,  204 
of  mucous  membranes  in,  204 
of  spleen  in,  300 
amyloid  degeneration  from,  311,  731 
cranio- tabes  in,  310 
cry  in,  310 
diagnosis  of,  211 
diet  in,  314 

epilepsy  resulting  from,  311 
eruption  in,  309 
mode  of  infection  in,  303 
morbid  anatomy  of,  203 
mucous  tubercles  in,  309 
paralysis  of  arms  in,  210 
prognosis  in,  318 
pseudo- paralysis  in,  310 
relapses  in,  211 
snuffling  in,  209 
state  of  nutrition  in,  211 
symptoms  of,  308 
treatment  of.  313 
Syringe -feeder,  the,  15 

Tabes  mesenterica,  183 
Tfenia  (see  Tape-worm),  706 

echinococcus,  737 

medio-cannellata,  706 

solium,  706 
Talking  in  sleep  in  cases  of  indigestion,  613 

usual  age  for  beginning,  396 
Tape-worm,  706 

seat  of,  707 

symptoms  of,  711 

treatment  of,  712 
Tapping  the  chest,  457 

the  pericardium,  165 
Tar  in  treatment  of  chronic  bronchiliis,  489 


840 


IT^DEX. 


Taste  blunted  in  idiocy,  394 

impaired  in  follicular  pharyngitis,  579 

in  paralysis  of  portio  dura,  368 
Teeth,  the  milk,  556 

incompleteness  of,  557 
order  of  eruption  of.  557 
retention  of,  into  adult  life,  560 
supernumerary,  557 
times  of  cutting,  556 
Teeth,  the  permanent,  notching  of,  in  in- 
fantile syphilis,  211 
order  of  cutting,  560 
Teething,  complications  of,  558 
derangements  of,  555 

diagnosis  of,  561 

treatment  of,  562 
diarrhoea  of,  559 

treatment  of,  562 
early,  in  infantile  syphilis,  200 

in  tubercular  children,  556 
influence  of,  upon  general  health,  555 
late  in  rickets,  138 
pyrexia  of,  558 
retarded,  557 
symptoms  of,  558 
Temper,  changes  in,  significance  of,  262 
irritability  of,  from    acid  dyspepsia, 
611 
Temperature  in  acute  rheumatism,  154 
in  ague,  148 

in  antemia,  idiopathic,  233 
in  atelectasis,  congenital,  462 

post-natal,  467 
in  atrophy,  infantile,  602 
in  bowels,  ulceration  of,  663 
in  brain,  congestion  of,  319 

hEemorrhage  into,  324 

tumour  of,  335 
in  Bright's  disease,  acute,  39 
in  bronchial  glands,  enlargement  of, 

180 
in  bronchitis,  capillary,  483,  484 
in  cancrum  oris,  568 
in  cerebral  apoplexy,  324 

congestion,  319 

sinuses,  thrombosis  of,  351 
in  cerebro-spinal  fever,  70 
in  chicken-pox,  48 
in  chorea,  303 
in  cyanosis,  538 
in  dentition,  558 
in  diarrhoea,  choleraic,  648 

inflammatory,  631 

simple,  626 
in  diphtheria,  93,  95 
in  dysentery,  650 
in  encephalitis,  351 
in  enteric  fever,  79 
in  epidemic  roseola,  30 
iu  erysipelas,  351 
in  fibroid  induration  of  lung,  477 
in  gangrene  of  lung,  498 

spontaneous,  170 
in  gastric  catarrh,  610 
in  heart,  congenital  malformation  of, 
538 


Temperature  in  hydrocephalus,  acute,  358, 
359,  361 

spurious,  632 
in  infancy,  10 

in  infantile  spinal  paralysis,  373 
in  intussusception,  670 
in  laryngismus  stridulus,  269 
in  laryngitis,  simple,  408 

stridulous,  412 

tuberculous,  416 
in  leucocythemia,  21 8 
in  lung,  collapse  of,  462,  470 

gangrene  of,  498 
in  lymphadenoma,  223 
in  measles,  22 
in  meningitis,  purulent,  349 

tubercular,  358,  359,  361 
in  mumps,  65 

in  oedema  of  new-born  infants,  808 
in  paralysis,  acute  infantile  spinal,  373 

pseudo-hypertrophic,  386 
in  pemphigus,  779 
in  pericarditis,  155 

suppurative,  157 
in  peritonitis,  acute,  687 

tubercular,  695 
in  peri-typhlitis,  681 
in  pharyngitis,  catarrhal,  577 

tubercular.  582 
in  phthisis,  pulmonary,  acute,  506 

chronic,  510 
in  pleurisy,  446 
in  pneumonia,  catarrhal,  436 

croupous,  427 
in  purpura,  250 
in  quinsy,  585 
in  rheumatism,  154 
in  rheumatism  of  abdominal  muscles, 

159 
in  rickets,  141 
in  scarlet  fever,  34,  35 
in  sclerema,  808 
in  scrofula,  181 
in  scurvy,  257 
in  small  pox,  56,  58,  61 
in  stomatitis,  aphthous,  563 

simple.  559 

ulcerative,  565 
in  teething,  558 
in  tetanus,  310 
in  tetany,  275 
in  thrush,  574 
in  tuberculosis,  195 
in  tumour  of  brain,  335 
in  typhlitis,  679 
in  ulceration  of  bowels,  663 
in  ulcerative  stomatitis,  565 
in  varicella,  48 
in  variola.  56,  58,  61 
in  whooping-cough,  115 
reduction  of,  in  hyper-pyrexia,  15 
sub-normal,  clinical  value  of.  11 
in  atelectasis,  congenital,  462 

post-natal,  467 
in  convalescence  from  acute  disease,  11 
in  cyanosis,  538 


INDEX. 


841 


Temperature  in  fasting  infants,  10 

in  infantile  atrophy,  602 
Tenderness,  general,  in  scurvy,  256 

in  severe  rickets,  137 
Tenesmus  in  cases  of  colitis,  632 

of  colitis,  treatment  of,  638 

of  dysentery,  649 

of  intussusception,  670 

of  polypus  of  rectum,  657 
Terrors,  night,  121 

treatment  of,  562 
Tetanus,  idiopathic,  308 

calabar  bean  in  treatment  of,  313 

causation  of,  308 

cessation  of  cry  in,  310 

chloral  in  treatment  of,  313 

diagnosis  of,  312 

duration  of,  311 

morbid  anatomy  of,  309 

opisthotonos  in,  310 

prognosis  in,  313 

rapid  wasting  in,  310 

sedatives  in  treatment  of,  313 

spasms  in,  310       , 

stiffness  of  jaws  in,  310 

temperature  in,  3lO 

tonic  rigidity  in,  310 

treatment  of,  313 
Tetany  (see  Extremities,  Tonic  Contraction 

of),  274 
Thermometer,  value  of,  11 
Thirst,  intense,  in  choleraic  diarrhoea,  643 

signs  of,  in  the  infant,  8 
Throat,  diseases  of  mouth  and,  555 

inflammation  of  (see  Pharyngitis),  576 

inspection  of,  13 
Thrombosis  of  heart,  98 

treatment  of,  108 

of  cerebral  sinuses  (see  Cerebral  Sin- 
uses), 650 
Thrush,  571 

applications  for,  575 

causation  of,  571 

diagnosis  of,  574 

diet  in,  575 

general  atrophy  in,  572 

morbid  anatomy  of,  572 

necessity  of  cleanliness  in  treatment 
of,  575 

oidium  albicans  of,  572 

prognosis  in,  574 

spurious  hydrocephalus  in,  573 

symptoms  of.  573 

temperature  in,  573 

treatment  of,  574 
Thymus  gland,  syphilitic  disease  of,  305 
Thyroid  body,  absence  of,  in  the  cretin,  393 
Tinea  circinata,  800 
Tinea  favosa,  804 

diagnosis  of,  805 

symptoms  of,  804 

treatment  of,  805 
Tinea  tonsurans,  799 

croton-oil  treatment  of,  803 

diagnosis  of,  801 

symptoms  of,  800 


Tinea  tonsurans,  treatment  of,  802 
Tongue,  appearance  of,  in  gastric  catarrh, 
611 

in  worms  in  the  alimentary  canal,  709 
Tongue,  ulceration  of,  in  whooping-cough, 

117 
Tonics,  general  value  of,  18 
Tonsils,  chronic  enlargement  of,  584 

alteration  of  features  from,  587 

causation  of,  584 

cough  from,  588 

deafness  from,  587 

effect  of,  on  general  health,  587 

hollow  breathing  from,  588 

morbid   anatomy  of,  585 

nasal  voice  from,  587 

symptoms  of,  586 

treatment  of,  589 
Tonsils,  inflammation  of  (see  Quinsy),  584 
Torticollis,  rheumatic,  159 
Trachea,  pressure  on,  causing  stertor,  182 
Tracheotomy,  accidents  after,  107 

in  membranous  croup,  105 
Tremours  in  cerebral  tumour,  333 

in  enteric  fever,  84 

in  tubercular  meningitis,  360 

significance  of,  263 
Tricophyton  tonsurans,  799 
Tube,  stomach-,  for  forced  feeding,  15 
Tubercular  meningitis,  355 

abdomen  in,  359 

anomalous  cases  of,  362 

breathing  in,  359 

causation  of,  355 

cerebral  flush  in,  359 

coma  in,  360 

constipation  in,  358 

convulsions  in,  360 

deceptive  improvement  in,  360 

diagnosis  of,  362 

from  acute  gastric  catarrh,  364 
from  cerebral  pneumonia,  364 
from  enteric  fever,  83 
from  malnutrition,  363 
from  simple  meningitis,  365 
from  spurious  hydrocephalus,  363 

drowsiness  in,  359 

fontanelle,  in,  360 

headache  in,  358 

insidious  beginning  of,  363 

morbid  anatomy  of,  356 

nystagmus  in,  360 

paralytic  stage  of,  360 

premonitory  stage  of,  357 

primary  form  of,  361 

prognosis  in,  365 

pulse  in,  358.  359,  361 

pupils  in,  359 

retention  of  urine  in,  359 

rigidity  of  joints  in,  360 

secondary  form  of,  361 

squinting  in,  359 

stage  of  invasion  of,  358 
of  irritation  of,  359 

symptoms  of,  357 

temperature  in,  358,  359,  361 


842 


IXDEX. 


Tubercular  meningitis,  tongue  in,  358 

treatment  of,  365 

twitchings  in,  360 

vomiting  in,  358 
Tuberculosis,  acute,  190 

bacillus  of,  191 

causation  of,  190 

diagnosis  of,  198 

from  acute  gastric  catarrh,  198 
from  infantile  atrophy,  199 
from  typhoid  fever,  88 

duration  of,  198 

forms  of,  190 

morbid  anatomy  of,  191 

oedema  of  legs  in,  195 

onset  of,  194 

physical  signs  of,  196 

prognosis  in,  200 

reduction  of  pyrexia  in,  300 

symptoms  of.  194 

secondary  to  empyema,  453 

temperature  in,  195 

treatment  of,  200 
Tumour  of  brain  (see  Cerebral  Tumour),  330 
Turpentine  as  an  anthelmintic,  713 
Tympanic  membrane,  rupture  of,  in  whoop- 
ing-cough, 118 
Tympanitis,  treatment  of,  692 
Typhlitis,  6:8 

causation  of,  678 

diagnosis  of,  682 

diet  in,  684 

prognosis  in,  683 

symptoms  of,  679 

treatment  of,  684 
Typhoid  fever  (see  Enteric  Fever),  74 

TJiiCREATiON  of  bowels  (see  Bowels,  Ul- 
ceration of),  660 
Ulceration  of  mucous  membrane  in  infan- 
tile syphilis,  204,  582 
in  lymphadenoma,  222 
in  ulcerative  stomatitis,  565 
Ulceration  of  throat  in  diphtheria,  93 
in  scarlet  fever,  34,  37 
in  tubercular  pharyngitis,  581 
Ulceration  of  vocal  cords  in  infantile  syph- 
ilis, 204 
in  tubercular  laryngitis,  416 
Ulceration,  sub-lingual,  in  whooping-cough, 

117 
Ulcerative  endocarditis,  154 

stomatitis  (see  Stomatitis,  Ulcerative), 
564 
Uinbilical  arteritis,  718 
Umbilical  phlebitis,  717 
diagnosis  of,  720 
pathology  of,  718 
prognosis  in,  720 
symptoms  of,  719 
treatment  of,  720 
Umbilical  vein,  haemorrhage  from,  654 
Umbilicus,  haemorrhage  from,  656,  717 
Unconsciousness  in  infants,  test   of,  262, 

338 
Uraemia,  blood  in  urine  in,  33 


Ursemia,  convulsions  in,  282 
Ursemic  poisoning,  cause  of,  33 

symptoms  of,  39,  282,  756 

treatment  of,  46 
Urea,  excretion  of,  increased  in  croupous 
pneumonia,  426 

in  the  child,  745,  758 
Ureter,  impaction  of  calculus  in,  766 
Uric  acid,  formation    of,  in   the   urinary 
passages,  763  " 

in  renal  ducts  a  cause  of  haematuria, 
765 

in  urine  a  cause  of  wetting    of   the 
bed,  748,  756,  765 

pain  in  urethra  from,  765 
Urinary  calculi,  763 

Urinary  casts  in  acute  desquamative  ne- 
phritis, 39 

in  chronic  Bright's  disease,  755 

in  passive  congestion  of  kidney,  746 
Urinary  deposits,  757,  758 
Urine,  albumen  in  (see  Albuminuria) 

blood  in  (see  Haematuria) 

characters  of  healthy,  745 

flow  of,  a  sign  of  recovery  in  convul- 
sions, 283 

in  ascites,  701 

in  acute  generalised  myelitis,  377 
phthisis,  506 
rheumatism,  154 
tuberculosis,  195 

in  ague,  149 

in  atrophic  cirrhosis  of  liver,  727 

in  Bright's  disease,  acute,  39 
chronic,  756 

in  cerebro- spinal  fever,  71 

in  chorea,  303 

in  congenital  disease  of  heart,  539 

in  cystitis,  tubercular,  197 

in  diphtheria,  95 

in  dysentery,  649 

in  enteric  fever,  78 

in  gastric  catarrh,  611 

in  haemorrhagic  purpura,  249 

in  hydronephrosis,  772 

in    hypertrophic    cirrhosis    of    liver, 
728 

in  icterus  neonatorum.  716 

in  infantile  tetanus,  310 

in  inflammatory  diarrhoea,  633 

in  leucocythemia,  224 

in  measles,  24 

in  membranous  croup,  89,  414 

in  pneumonia,  croupous.  426 

in  rheumatism  of  abdominal  muscles, 
159 

in  rickets,  1 34 

in  sarcoma  of  kidney,  770 

in  scarlet  fever,  39 

in  scurvy.  257 

in  spontaneous  gangrene,  170 

in  thrush,  severe  cases  of,  574 

in  ulcerative  endocarditis,  158 

in  umbilical  phlebitis,  719 

indican  in,  test  for,  635 

milky,  from  urates,  745 


INDEX. 


843 


Urine,  nocturnal  incontinence  of,  748 

a  symptom  of  epilepsy,  291 
of  sand  in  water,  765 
of  small-pox,  61 

causation  of,  748 

pathology  of,  749 

treatment  of,  750 
Urine,  offensive,  from  catarrh  of  bladder, 

746 
Urine,  retention  of,  causes  of,  748 

from  thread-worms,  748 

in  dysentery,  649 

in  enteric  fever,  78 

in  peritonitis,  acute,  687 

in  tubercular  meningitis,  359 

in  tumour  of  medulla  oblongata,  337 
Urine,  scanty  secretion  of,  744 

in  choleraic  diarrhcea,  643 
Urine,  yellow,  from  bile  pigment,  746 
Urticaria,  785 

diagnosis  of,  786 

in  cases  of  purpura,  248 

symptoms  of,  785 

treatment  of,  786 
Urticaria  pigmentosa,  786 
Uvula,  destruction  of,  in  tubercular  pha- 
ryngitis, 582 

oedematous  in  quinsy,  585 

Vaccination,  51 

eificient,  53 

in  treatment  of  eczema,  795 

mode  of  operating  in,  53 

protective  value  of,  53 

sequelae  of,  53 

temperature  in,  52 
Valvular    disease    of    heart    (see    Heart, 

Chronic  Valvular  Disease  of),  544 
Varicella  (see  Chicken-pox),  48 
Variola  (see  Small-pox),  55 
Varioloid,  61 

diagnosis  of,  from  varicella,  49 
Veins,    fulness  of  superficial,  in  catarrhal 
pneumonia,  437 

in  cirrhosis  of  liver,  728 
of  lung,  477 

in  enlarged  bronchial  glands,  181 

in  tubercular  peritonitis,  695 
Venous    hum    from    enlarged     bronchial 

glands,  183 
Ventilation  of  bed-rooms,  importance  of, 

234 
Vermiform  appendix,  ulceration  of ,  678 

diagnosis  of,  683 

peritonitis  from,  683 

prognosis  in,  683 

symptoms  of,  683 
Vibration,  vocal,  often  absent  in  children, 

401 
Vision,  disorders  of,  in  megrim,  295 

impaired,  in  cerebral  tumour,  382,  388 
Vocal  cords,  ulceration  of,  syphilitic,  204 

tubercular,  416 
Voice,  alteration  of,  in  anemia  of  larynx, 
409 

in  chronic  laryngitis,  408 


Voice,  alteration  of,  in  foreign  body  in  air- 
tubes,  530 

in  infantile  syphilis,  210 

in  membranous  croup,  95 

in  scald  of  glottis,  407 

in  stridulous  laryngitis,  412 

in  suppuration  about  krnyx,  430 

in  tubercular  laryngitis,  416 

in  warty  growths  on  larynx,  417 
Voice,  nasal,  in  enlargement  of  tonsils,  587 

in  quinsy,  585 

in  retro-pharyngeal  abscess,  592 

in  tubercular  pharyngitis,  582 
Vomiting  a  sign  of  cardiac  failure,  99 

cerebral,  264,  558 

chronic  in  infants,  treatment  of,  607 

clinical  importance  of,  3 

in  amyloid  liver,  732 

in  atrophic  cirrhosis  of  liver,  728 

in  capillary  bronchitis,  484 

in  cerebral  tumour,  332 
treatment  of,  339 

in  choleraic  diarrhoea,  643 

in  chronic  Bright' s  disease,  755 

in  fibroid  induration  of  lung,  477 

in  gastric  catarrh,  611 

in  idiopathic  anaemia,  233 

in  infantile  atrophy,  607 

in  inflammatory  diarrhoea,  631 

in  intussusception,  673 

in  lymphadenoma,  324 

in  malignant  diphtheria,  97 

in  peritonitis,  simple  acute,  687 

in  peri-typhlitis,  679 

in  symmetrical  gangrene,  168 

in  typhlitis,  679 

in  tubercular  meningitis,  358 

in  umbilical  phlebitis,  719 

in  whooping-cough  a  cause  of  danger^ 
118 
Vulva,  gangrene  of,  170 

treatment  of,  171 
Vulvitis,  aphthous,  776 

diagnosis  of,  776 

symptoms  of,  776 

treatment  of,  777 
Vulvitis,  catarrhal,  775 

symptoms  of,  775 

treatment  of,  776 

Walk,  peculiarities  of,   in  cerebellar  tu- 
mour, 337 

in  pseudo-hypertrophic  paralysis,  385 

in  spasmodic  spinal  paralysis,  383 
Walking  late  in  chronic  hydrocephalus,  3i3 

in  idiocy,  392 

in  rickets,  143 
Warty  growths  on  vocal  cords,  case  of,  41 7 
Wasting,  general,  from  deficient  nourish- 
ment, 596 
Wasting  of  mnscle  in  acute  infantile  spinal 
paralysis,  375 

in  chorea,  303 

in  haemorrhage  into  spinal  cord,  377 

in  pseudo-hypertrophic  paralysis,  386 

in  rickets,  134 


844 


IISTDEX. 


Wasting  of  third  cerebral  nerve  from  pres- 
sure, 375 
rapid,  in  choleraic  diarrhoea,  643 
Wetting  the  bed  a  symptom  of  epilepsy,  391 
of  sand  in  water,  765 
of  small-pox,  61 
Wetting  the  bed  (see  Urine,  Nocturnal  In- 
continence of),  748 
White  lead  paint  as  an  application  for  ery- 
sipelas, 113 
White  wine  whey,  608 

in  treatment  of  gastric  catarrh  in  in- 
fants, 608 
in  treatment  of  post-natal  atelectasis, 

464 
in  treatment  of  thrush,  575 
Whoop,  occasional  absence  of,  in  pertussis, 

117 
Whooping-cough,  109 

absence  of  whoop  in,  117 

antiseptic  sprays  in  treatment  of,  126 

atropia  in  treatment  of,  124 

bacillus  of,  115 

bronchitis  in,  120 

catarrhal  pneumonia  in,  120 

stage  of,  116 
causation  of,  114 
collapse  of  lung  in,  119 
complications  of,  117 
convulsions  in,  119 
diagnosis  of,  128 
treatment  of,  127 
croton  chloral  in  treatment  of,  126 
diagnosis  of,  122 


Whooping-cough,  diet  in,  134 

digestive  derangements  in,  118 

duration  of,  117 

of  infection  in,  114 

emphysema  of  lungs  in,  120 

epistaxis  in,  117 

fungus  of,  115 

haemorrhages  in,  116 

morbid  anatomy  of,  114 

mucous  disease  after,  121 

nature  of,  115 

nervous  accidents  in,  118 
agitation  in,  115 

paroxysms  of,  116 

pathology  of,  114 

physiognomony  of,  7 

prognosis  in,  123 

pulmonary  lesions  in,  119 

quirdne  in  treatment  of,  135 

rupture  of  tympanic  membrane  in,  118 

sequelae  of,  120 

spasm  of  larynx  in,  118 
treatment  of,  127 

spasmodic  stage  of,  116 

sub-lingual  ulceration  in,  117 

symptoms  of,  115 

treatment  of,  124 

vomiting  in,  a  cause  of  danger,  118 
Worms,  intestinal,  705 

causation  of,  707 

diagnosis  of,  711 

symptoms  of,  708 

treatment  of,  711 

varieties  of,  705 


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